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Grinspon RP, Castro S, Rey RA. Up-to-Date Clinical and Biochemical Workup of the Child and the Adolescent with a Suspected Disorder of Sex Development. Horm Res Paediatr 2021; 96:116-127. [PMID: 34781296 DOI: 10.1159/000519895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/21/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The suspicion of a disorder of sex development (DSD) often arises at birth, when the newborn presents with ambiguous genitalia, or even during prenatal ultrasound assessments. Less frequently, the aspect of the external genitalia is typically female or male, and the diagnosis of DSD may be delayed until a karyotype is performed for another health issue, or until pubertal age when a girl presents with absence of thelarche and/or menarche or a boy consults for gynaecomastia and/or small testes. SUMMARY In this review, we provide a practical, updated approach to clinical and hormonal laboratory workup of the newborn, the child, and the adolescent with a suspected DSD. We focus on how to specifically address the diagnostic approach according to the age and presentation. Key Message: We particularly highlight the importance of a detailed anatomic description of the external and internal genitalia, adequate imaging studies or surgical exploration, the assessment of reproductive hormone levels - especially testosterone, anti-Müllerian hormone, 17-hydroxyprogesterone, and gonadotropins - and karyotyping.
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Affiliation(s)
- Romina P Grinspon
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Buenos Aires, Argentina
| | - Sebastián Castro
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Buenos Aires, Argentina
| | - Rodolfo A Rey
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Buenos Aires, Argentina.,Universidad de Buenos Aires, Facultad de Medicina, Departamento de Histología, Embriología, Biología Celular y Genética, Buenos Aires, Argentina
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2
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Onuma S, Fukuoka T, Miyoshi Y, Fukui M, Satomura Y, Yasuda K, Kimura T, Tachibana M, Bessho K, Yamamoto T, Tanaka H, Katsumata N, Fukami M, Hasegawa T, Ozono K. Two girls with a neonatal screening-negative 21-hydroxylase deficiency requiring treatment with hydrocortisone for virilization in late childhood. Clin Pediatr Endocrinol 2021; 30:143-148. [PMID: 34285457 PMCID: PMC8267553 DOI: 10.1297/cpe.30.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/20/2021] [Indexed: 11/09/2022] Open
Abstract
Herein, we report two girls with a neonatal screening (NS)-negative 21-hydroxylase
deficiency (21-OHD) requiring treatment with hydrocortisone due to virilization that
developed in late childhood. Patient 1 was born prematurely on the 30th gestational week
with normal external genitalia at birth. She passed the NS for 21-OHD. At 6 yr of age, she
was referred to a hospital for evaluation of premature pubarche and clitoromegaly. Her
diagnosis was central precocious puberty, and GnRH agonist was initiated. However, her
symptoms did not improve despite treatment for over 4 years. She was then referred to our
hospital where she was diagnosed with 21-OHD. Although she was started on hydrocortisone
therapy, her adult height reached only 140 cm (−3.4 SD). Patient 2 was delivered at 37
weeks of gestation and passed the NS for 21-OHD. She was referred to a hospital because of
premature pubarche at the age of 6 yr. She was diagnosed with 21-OHD, and hydrocortisone
replacement therapy was initiated. Her present height at 13 yr of age is 148 cm (−1.3 SD).
These cases reminded us that the possibility of 21-OHD should be considered when patients
show premature pubarche or precocious puberty, even if they passed the NS test for
21-OHD.
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Affiliation(s)
- Shinsuke Onuma
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoya Fukuoka
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoko Miyoshi
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Health and Nutrition, Faculty of Health and Nutrition, Osaka Shoin Women's University, Osaka, Japan
| | - Miho Fukui
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshinori Satomura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kie Yasuda
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Kimura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makiko Tachibana
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hiroyuki Tanaka
- Department of Pediatrics, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Noriyuki Katsumata
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Maki Fukami
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
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Savaş-Erdeve Ş, Aycan Z, Çetinkaya S, Öztürk AP, Baş F, Poyrazoğlu Ş, Darendeliler F, Özsu E, Şıklar Z, Demiral M, Unal E, Özbek MN, Gürbüz F, Yüksel B, Evliyaoğlu O, Akyürek N, Berberoğlu M. Clinical Characteristics of 46,XX Males with Congenital Adrenal Hyperplasia. J Clin Res Pediatr Endocrinol 2021; 13:180-186. [PMID: 33374095 PMCID: PMC8186342 DOI: 10.4274/jcrpe.galenos.2020.2020.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To retrospectively evaluate the follow-up data in patients with 46,XX congenital adrenal hyperplasia (CAH) who were raised male. METHODS A national database was created. The data of patients were asked to be recorded in the data form. RESULTS The median (range) age of diagnosis was three (0.1-18.3) years in 44 patients. Twenty nine cases were diagnosed after the age of two years. Most (95.4%) cases were stage 4-5 virilized. Hysterectomy and bilateral salpingoopherectomy, at a median age of 7.25 (2.4-25.3) years, was performed in 35 cases. Testicular prostheses were placed in 11 (25%) cases at a median age of 11.2 (2.8-17) years. The median final height was 149.2 (132.8-172) cms in 38 patients, including simple virilizing (n=18), salt-wasting (n=6), and 11-beta hydroxylase (n=12). Of the 16 patients above the age of eighteen, university education was completed in 25%. CONCLUSION It was seen that most (65.9%) of the 46,XX CAH cases raised male were diagnosed after two years of age. In these cases, hysterectomy and bilateral salpingoopherectomy, genital corrective surgeries and testicular prosthesis operations were performed in a very wide age rage.
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Affiliation(s)
- Şenay Savaş-Erdeve
- University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey,* Address for Correspondence: University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey E-mail:
| | - Zehra Aycan
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Semra Çetinkaya
- University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Ayşe Pınar Öztürk
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Firdevs Baş
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Şükran Poyrazoğlu
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Feyza Darendeliler
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Elif Özsu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Meliha Demiral
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Edip Unal
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Mehmet Nuri Özbek
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Bilgin Yüksel
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Olcay Evliyaoğlu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Nesibe Akyürek
- University of Health Sciences Turkey, Konya Training and Research Hospital, Clinic of Pediatric Endocrinology, Konya, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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de Jesus LE, Costa EC, Dekermacher S. Gender dysphoria and XX congenital adrenal hyperplasia: how frequent is it? Is male-sex rearing a good idea? J Pediatr Surg 2019; 54:2421-2427. [PMID: 30905417 DOI: 10.1016/j.jpedsurg.2019.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/26/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The frequency of gender dysphoria (GD) among 46,XX congenital adrenal hyperplasia (CAH) patients is unknown. These data are needed to put into perspective the debate about the timing of reconstructive surgery and possible male-raising of the most severely virilized children. OBJECTIVE To analyze the frequency of female to male GD between 46,XX individuals raised as females; to identify subgroups with higher chances of showing GD; to describe the results of male-raising among 46,XX CAH patients. MATERIALS AND METHODS Analytic/descriptive literature review (January 1988 to April 2018). RESULTS Female-raised patients frequently report the desire to be male, adopt male-typical behavior and are frequently homosexual/bisexual as adults, but this does not correspond to GD. Declared GD among 46,XX CAH patients attained 9% of the reported cohorts, generally in late adolescence/adulthood. We could not prove a relationship between inadequate treatment, null-genotype, late diagnoses, a higher degree of virilization, type of CAH or higher levels of androgens and female to male GD, but this may be due to statistical limitations. Male gender raised patients (MGR) were 10.1% of CAH cohorts included in this review, mostly from underdeveloped countries, with a high proportion of late diagnoses (76.3%) and familial choices. GD was more common in this group than among female-raised patients. Opting for male gender relates to a short final height, the need for multiple surgeries, surgical castration before puberty and infertility. CONCLUSION Both male to female and female to male GD may present in 46,XX CAH patients in a contemporaneous cohort. The proportion of GD is higher among patients raised as males. DSD patients sexual maladjustments are complex and not comparable to the transgender population. Many 46,XX CAH patients with GD define themselves as gender-fluid and do not seek for legal/formal transition. Male-raising Prader 4/5 46,XX CAH patients imply infertility and multiple surgeries. There is no proof that any subgroup of CAH is more prone to GD, despite null genotypes, salt wasting phenotypes and Prader 4/5 cases being related to male-typical behavior and female homosexuality. TYPE OF STUDY Descriptive/analytic non-systematic REVIEW. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lisieux Eyer de Jesus
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil; Pediatric Surgery and Urology Department, Antonio Pedro University Hospital, UFF, Rio de Janeiro, Brazil.
| | - Eduardo Corrêa Costa
- Pediatric Surgery and Urology Department, Porto Alegre Clinics Hospital, UFRS, Porto Alegre, Brazil
| | - Samuel Dekermacher
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil
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5
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Goyal A, Boro H, Khadgawat R. Male Gender Identity and Reversible Hypokalemic Hypertension in a 46,XX Child with 11-Beta-Hydroxylase Deficiency Congenital Adrenal Hyperplasia. Cureus 2019; 11:e5248. [PMID: 31572633 PMCID: PMC6760881 DOI: 10.7759/cureus.5248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Steroid 11-beta-hydroxylase deficiency is a relatively rare form of congenital adrenal hyperplasia (CAH). We describe the case of a 46,XX child, reared as a male, who first presented to us at the age of three years with features of peripheral precocity and hypokalemic hypertension. Based on the clinical and biochemical profile, a diagnosis of 11-beta-hydroxylase deficiency CAH was established, and physiological glucocorticoid replacement was begun. Both hypertension and hypokalemia improved with glucocorticoid supplementation, and at eight years of age, antihypertensives were successfully withdrawn. Regression of left ventricular hypertrophy was also noted at this time. In keeping with the male gender identity, the child underwent hysterectomy, oopherectomy and breast reduction surgery at 13 years of age. We conclude that both hypertension and end-organ damage due to 11-beta-hydroxylase CAH may get reversed following optimal glucocorticoid treatment. Detailed genital examination at birth may help in early diagnosis of this rare disorder, thereby preventing the deleterious consequences of longstanding mineralocorticoid excess.
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Affiliation(s)
- Alpesh Goyal
- Endocrinology, All India Institute of Medical Sciences, New Delhi, IND
| | - Hiya Boro
- Endocrinology, All India Institute of Medical Sciences, New Delhi, IND
| | - Rajesh Khadgawat
- Endocrinology, All India Institute of Medical Sciences, New Delhi, IND
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Bin-Abbas B, Al-Humaida D, Al-Sagheir A, Qasem E, Almohanna M, Alzahrani AS. Divergent gender identity in three siblings with 46XX karyotype and severely virilizing congenital adrenal hyperplasia caused by a novel CYP11B1 mutation. Endocr Pract 2019; 20:e191-7. [PMID: 25100385 DOI: 10.4158/ep14179.cr] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe conflicting gender identities in three karyotypically female siblings with congenital adrenal hyperplasia (CAH) caused by a novel mutation in the CYP11B1 gene, who were assigned as males at birth and followed up to adulthood. METHODS We present 3 siblings (16, 14 and 10 years old) who were born with severe genital virilization and raised as males. Clinical examination showed Prader IV to V external genitalia with a stretched penile length of 7 to 11 cm. Adrenocorticotrophic hormone (ACTH) stimulation test showed a stimulated 11 deoxycortisol (11DOC) level of 12,300-18,700 μg/L (normal 0-5 μg/L). Their karyotypes were 46 XX, and they had normal-sized uterus and ovaries on pelvic ultrasound. DNA was isolated from peripheral leukocytes, and polymerase chain reaction (PCR) and direct sequencing revealed a novel CYP11B1 mutation. This mutation leads to a c.53_54 T insertion (c.53_54insT) with frameshift and truncation at c.115 (codon 39) of CYP11B1. RESULTS Psychological evaluation of the oldest sibling suggested a female gender identity, and she declared herself as female, and female sex was re-assigned after 1 year of psychosocial adjustment. Psychological assessment for the 2 younger siblings and a fourth 46XY sibling with the same condition revealed male gender identities, and they continued their lives as males without significant difficulties. CONCLUSION Divergent gender identity was observed in three severely masculinized 46XX siblings with CAH who carried the same CYP11B1 mutation and had comparable postnatal and probably prenatal androgen exposure and environmental circumstances. These cases suggest that the basis of gender identity is more complex than chromosomal, biochemical, and genetic constitution.
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Affiliation(s)
- Bassam Bin-Abbas
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Doha Al-Humaida
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Afaf Al-Sagheir
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ebtesam Qasem
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mai Almohanna
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali S Alzahrani
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Apóstolos RAC, Canguçu-Campinho AK, Lago R, Costa ACS, Oliveira LMB, Toralles MB, Barroso U. Gender Identity and Sexual Function in 46,XX Patients with Congenital Adrenal Hyperplasia Raised as Males. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:2491-2496. [PMID: 30291599 DOI: 10.1007/s10508-018-1299-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 06/08/2023]
Abstract
In individuals with congenital adrenal hyperplasia (CAH) and 46,XX karyotype, androgens produced by the adrenal glands during the intrauterine development promote virilization of the genitals, which may even result in the development of a well-formed penis. Some of these children with late diagnosis are registered as males after birth. After obtaining approval from the internal review board, we evaluated gender identity and sexual function in four 46,XX severely virilized patients with CAH, who were originally registered and raised as males, assisted in our Disorders of Sexual Development Clinic. The evaluation consisted of questionnaires to assess gender identity and sexual activity and interview with the multidisciplinary team that provides care for these patients. The patients underwent surgery to remove uterus, ovaries, and remaining vaginal structures, in addition to implantation of testicular prosthesis and correction of hypospadias, when necessary. All four patients have developed a clear male gender identity, and when evaluated for sexual activity, they have reported having erections, libido, orgasms, and sexual attraction to women only. Two of these 4 patients had satisfactory sexual intercourses when assessed using the International Index of Erectile Function questionnaire. The other two patients who never had sexual intercourse reported not having a partner for sexual activity; one is 18 years old, and the other is 14 years old. This study showed that this group of 46,XX severely virilized patients with CAH, registered and raised as males, adapted well to the assigned male gender, with satisfactory sexual function in patients who had sexual intercourse.
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Affiliation(s)
- Robson A C Apóstolos
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Ana Karina Canguçu-Campinho
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Renata Lago
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | | | - Luciana M B Oliveira
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Maria Betania Toralles
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Ubirajara Barroso
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil.
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil.
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Fleming L, Van Riper M, Knafl K. Management of Childhood Congenital Adrenal Hyperplasia-An Integrative Review of the Literature. J Pediatr Health Care 2017; 31:560-577. [PMID: 28416079 PMCID: PMC5654644 DOI: 10.1016/j.pedhc.2017.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is an endocrine condition that requires parents to administer steroids up to three times daily, supplementing maintenance doses with oral or injectable doses during times of illness. The purpose of this integrative review was to explore the management, care, and associated health issues for children with CAH and the family response to the condition. Four literature indexes were searched, with 39 articles included. Four themes emerged: (a) Health- and Development-Related Issues, (a) Effects of Excess Androgens, (c) Life Experience of CAH, and (d) Managing and Averting Adrenal Crisis. Families having a child with CAH face complex concerns related their child's growth, the fear of adrenal crisis events, and the consequences of atypical genitalia for affected girls. Future studies should focus on interventions that provide guidelines to increase parental preparedness in managing adrenal crises and creating support systems for affected girls.
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Razzaghy-Azar M, Karimi S, Shirazi E. Gender Identity in Patients with Congenital Adrenal Hyperplasia. Int J Endocrinol Metab 2017; 15:e12537. [PMID: 29201068 PMCID: PMC5701969 DOI: 10.5812/ijem.12537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/23/2017] [Accepted: 07/02/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sex assignment in infancy for patients with disorder of sex development (DSD) is a challenging problem. Some of the patients with congenital adrenal hyperplasia (CAH) have DSD that may affect their gender identity. OBJECTIVES The study aimed to assess gender identity in patients with CAH. METHODS In this study, 52 patients with CAH, including 22 prepubertal children and 30 adolescents and adults, were assessed using two separate gender identity questionnaires for children and adults based on the criteria of diagnostic and statistical manual of mental disorders, 5th edition. RESULTS In the children group, compatibility was seen between gender identity and rearing gender. In the adult group, there were three cases of mismatching between gender identity and sex assignment composed of two females with poor control and one male with good control with 21-hydroxylase deficiency (21-OHD). Three girls with 11-hydroxylase deficiency (11-OHD) were reared as boy. Two of them with late diagnosis at 5 and 6 years of age had pseudoprecocious puberty. Parents and children did not accept to change the gender. One of them is 36 years old now, is depressed and unsatisfied with her gender, another girl is still child and has male sexual identity. One girl with 11-OHD and early diagnosis at birth with Prader 5 virilization but with good hormonal control was changed to female gender at 12 years of age when female sexual characteristics appeared; she is 34-years-old now, married, and with two children, and she is satisfied with her gender. CONCLUSIONS In patients with CAH, gender identity disorder is a rare finding. Hormonal control, social, familial, and religious beliefs have impacts on gender identity of these patients.
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Affiliation(s)
- Maryam Razzaghy-Azar
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Maryam Razzaghy-Azar, M.D., 193 H. Ali-Asghar Children’s Hospital, East Dastgerdi Street, Modarress Exp. Way, 1919816766, Tehran, Iran. E-mail:
| | - Sakineh Karimi
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Shirazi
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
- Mental Health Research Center, Tehran Institute of Psychiatry-School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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Khattab A, Yau M, Qamar A, Gangishetti P, Barhen A, Al-Malki S, Mistry H, Anthony W, Toralles MB, New MI. Long term outcomes in 46, XX adult patients with congenital adrenal hyperplasia reared as males. J Steroid Biochem Mol Biol 2017; 165:12-17. [PMID: 27125449 DOI: 10.1016/j.jsbmb.2016.03.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/12/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023]
Abstract
Patients with Congenital Adrenal Hyperplasia (CAH) owing to 21-hydroxylase deficiency and whose karyotype is 46, XX are usually assigned to the female gender. Reported herein are the long term outcomes in three patients with CAH whose karyotype is 46, XX and who were reared as males. A retrospective review of three CAH patients with a 46, XX karyotype who were reared as males was conducted. Gender assignment, clinical and biochemical data, pre and post-genitoplasty genital examinations were reviewed. Gender identity was tested by an extensive questionnaire. Gender role, sexual preference, marital status and sexual satisfaction were evaluated by interview. The three patients were genotyped for the CYP21A2 gene confirming the diagnosis of CAH. Owing to genital virilization, cultural preferences for male gender and the lack of newborn screening programs the three patients reported herein were assigned to the male gender at birth before the diagnosis of CAH was established. In adulthood the patients remained significantly virilized. Thorough psychosexual assessments in adulthood revealed well established male gender identities compatible with their male gender assignments at birth. In all three patients, gender role and behavior were consistent with male gender identity including sexual intercourse with female partners. The three patients reported herein revealed that male gender assignment to CAH patients with a 46, XX karyotype may have a successful outcome providing there is strong parental support and expert endocrine care. No standard guidelines have been published for the gender assignment of CAH patients with a 46, XX karyotype and genital ambiguity. More studies concerning gender assignment in CAH patients with a 46, XX karyotype reared as males are needed.
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Affiliation(s)
- A Khattab
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M Yau
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Qamar
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - P Gangishetti
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Barhen
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - S Al-Malki
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - H Mistry
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - W Anthony
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M B Toralles
- Genetica Medica, Universidade Federal da Bahia, Salvador, State of Bahia, Brazil
| | - Maria I New
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
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11
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Abstract
Great controversies and misunderstandings have developed around the relatively recently coined term disorders of sex development (DSD). In this article, we question the wisdom of including XX individuals with congenital adrenal hyperplasia (CAH) in the DSD category and develop arguments against it based on the published literature on the subject. It is clear that females with CAH assigned the female gender before 24 months of age and properly managed retain the female gender identity regardless of the Prader grade. Females with CAH and low Prader grades have the potential for a normal sexual and reproductive life. Those with greater degrees of prenatal androgen exposure (Prader grades IV and V) raised as females also identify themselves as females but experience more male-like behavior in childhood, have a greater rate of homosexuality, and have greater difficulty with vaginal penetration and maintaining pregnancies. Improvement in surgical techniques, better endocrinological, psychological, and surgical follow-up may lessen these problems in the future. Given the fact that the term DSD includes many conditions with problematic gender identity and conflicts with the gender assigned at birth, it may be appropriate to exclude females with CAH from the DSD classification.
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Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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12
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Pasterski V, Zucker KJ, Hindmarsh PC, Hughes IA, Acerini C, Spencer D, Neufeld S, Hines M. Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia: Results from a Standardized Assessment of 4- to 11-Year-Old Children. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1363-75. [PMID: 25239661 DOI: 10.1007/s10508-014-0385-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 08/18/2014] [Accepted: 08/21/2014] [Indexed: 05/02/2023]
Abstract
While reports showing a link between prenatal androgen exposure and human gender role behavior are consistent and the effects are robust, associations to gender identity or cross-gender identification are less clear. The aim of the current study was to investigate potential cross-gender identification in girls exposed prenatally to high concentrations of androgens due to classical congenital adrenal hyperplasia (CAH). Assessment included two standardized measures and a short parent interview assessing frequency of behavioral features of cross-gender identification as conceptualized in Part A of the diagnostic criteria for gender identity disorder (GID) in the DSM-IV-TR. Next, because existing measures may have conflated gender role behavior with gender identity and because the distinction is potentially informative, we factor analyzed items from the measures which included both gender identity and gender role items to establish the independence of the two constructs. Participants were 43 girls and 38 boys with CAH and 41 unaffected female and 31 unaffected male relatives, aged 4- to 11-years. Girls with CAH had more cross-gender responses than female controls on all three measures of cross-gender identification as well as on a composite measure of gender identity independent of gender role behavior. Furthermore, parent report indicated that 5/39 (12.8 %) of the girls with CAH exhibited cross-gender behavior in all five behavioral domains which comprise the cross-gender identification component of GID compared to 0/105 (0.0 %) of the children in the other three groups combined. These data suggest that girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification than girls without CAH or boys with and without CAH. Our findings suggest that prenatal androgen exposure could play a role in gender identity development in healthy children, and may be relevant to gender assignment in cases of prenatal hormone disruption, including, in particular, cases of severely virilized 46, XX CAH.
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Affiliation(s)
- Vickie Pasterski
- Department of Psychology, Free School Lane, University of Cambridge, Cambridge, CB2 3RQ, UK,
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13
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Pasterski V, Mastroyannopoulou K, Wright D, Zucker KJ, Hughes IA. Predictors of posttraumatic stress in parents of children diagnosed with a disorder of sex development. ARCHIVES OF SEXUAL BEHAVIOR 2014; 43:369-375. [PMID: 24085468 DOI: 10.1007/s10508-013-0196-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 06/05/2013] [Accepted: 08/19/2013] [Indexed: 05/28/2023]
Abstract
The aims of the current study were twofold: (1) to assess the prevalence/severity of posttraumatic stress symptoms (PTSS) as well as cognitive and emotional responses in parents whose children were diagnosed with a disorder of sex development (DSD); and (2) to assess factors which contributed to PTSS. We hypothesized that parents would show elevated levels of PTSS and that negative cognitive and/or emotional responses would be predictive. Participants were parents of children diagnosed with a DSD. Thirty-six mothers and 11 fathers completed a measure of posttraumatic stress and reported difficulties in the domains of cognition (e.g., confusion) and emotion (e.g., grief). Using multiple regression, we determined factors contributing to parental PTSS. Reported PTSS was high: 31 % of mothers and 18 % of fathers met the threshold for caseness for Posttraumatic Stress Disorder. Regression included: child sex, parent sex, child age at diagnosis, years since diagnosis, genital ambiguity, father occupation, cognitive confusion, and emotional distress. Only cognitive confusion contributed significantly to variance in PTSS. Parents of children with DSD may experience the diagnosis as traumatic, evidenced by high rates of PTSS in the current report. Assessment of reactions to their children's diagnoses revealed that cognitive confusion, and not emotional distress, predicted PTSS. In this case, direct cognitive interventions may be applicable. Though psychological support is widely recommended, no detailed intervention has been offered. Our findings suggest that we may directly apply models successful in other areas of pediatrics, such as pediatric oncology. Future studies may assess the usefulness of such an intervention.
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Affiliation(s)
- Vickie Pasterski
- Department of Paediatrics, Addenbrooke's Hospital, Box 116, Level 8, Hills Road, Cambridge, CB2 0QQ, UK,
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14
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González R, Ludwikowski BM. Gender Dysphoria in 46,XX Persons with Adrenogenital Syndrome Raised as Females: An Addendum. Front Pediatr 2014; 2:140. [PMID: 25610825 PMCID: PMC4285136 DOI: 10.3389/fped.2014.00140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/14/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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15
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Gosetti F, Mazzucco E, Gennaro MC, Marengo E. Ultra high performance liquid chromatography tandem mass spectrometry determination and profiling of prohibited steroids in human biological matrices. A review. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 927:22-36. [DOI: 10.1016/j.jchromb.2012.12.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 12/03/2012] [Accepted: 12/04/2012] [Indexed: 01/15/2023]
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16
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Abstract
Disorders of sex development (DSDs) are estimated to be prevalent in 0.1-2% of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation-processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5-20% of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63%). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.
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17
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Janzen N, Sander S, Terhardt M, Steuerwald U, Peter M, Das AM, Sander J. Rapid steroid hormone quantification for congenital adrenal hyperplasia (CAH) in dried blood spots using UPLC liquid chromatography-tandem mass spectrometry. Steroids 2011; 76:1437-42. [PMID: 21839763 DOI: 10.1016/j.steroids.2011.07.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 07/24/2011] [Accepted: 07/25/2011] [Indexed: 11/24/2022]
Abstract
Newborn screening for congenital adrenal hyperplasia (CAH) is usually done by quantifying 17α-hydroxyprogesterone using immunoassay. However, this test produces high rates of false positive results caused by cross reacting steroids. Therefore we have developed a selective and specific method with a short run time (1.25 min) for quantification of 17α-hydroxyprogesterone, 21-deoxycortisol, 11-deoxycortisol, 11-deoxycorticosterone and cortisol from dried blood spots. The extraction procedure is very simple and steroid separation is ensured on a BEH C18 column and an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Analysis was done in positive ionization mode (ESI+) and recorded in multiple reaction monitoring mode (MRM). The method gave linear results for all steroids over a range of 5-200 (cortisol: 12.5-500)nmol/L with coefficients of regression >0.992. Absolute recovery was >64.1%. Across the analytical range the inter-assay coefficient of variation (CV) was <3%. Newborn blood samples of patients with confirmed 21-CAH and 11-CAH could clearly be distinguished from samples of unaffected newborns falsely positive on immunoassay. The method is not influenced by cross reactions as found on immunoassay. Analysis of dried blood spots shows that this method is sensitive and fast enough to allow rapid analysis and can therefore improve the newborn screening program.
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Affiliation(s)
- Nils Janzen
- Clinic for Pediatric Kidney-, Liver- and Metabolic Diseases, Hannover Medical School, Hannover, Germany.
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18
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Barthold JS. Disorders of Sex Differentiation: A Pediatric Urologist's Perspective of New Terminology and Recommendations. J Urol 2011; 185:393-400. [DOI: 10.1016/j.juro.2010.09.083] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Indexed: 11/30/2022]
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19
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Review of Outcome Information in 46,XX Patients with Congenital Adrenal Hyperplasia Assigned/Reared Male: What Does It Say about Gender Assignment? INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:982025. [PMID: 21197442 PMCID: PMC3010645 DOI: 10.1155/2010/982025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/14/2010] [Accepted: 11/26/2010] [Indexed: 01/06/2023]
Abstract
There is ample historical verification of 46,XX congenital adrenal hyperplasia (CAH) patients being born with essentially male genitaliawhile outcome information is scant. Prior to glucocorticoid therapy, most patients died very young from adrenal insufficiency. Most available reports from laterchildhood, contain little information concerning sexual identity. Reports on older individuals lack adequate information about sexual identity and quality of life. The difficulty in assessing the relative impact of multiple dynamic environmental factors on the development of sexual identity, self- and body esteem and overall adjustment to life is clear. Nevertheless, it remains unclear whether those infants whose masculine genitalia at birth resulted in an initial male assignment would have enjoyed a better adult outcome had they been allowed to remain male rather than the female reassignment that most received. Further, one could ask whether a male sex of rearing should be considered in 46,XX CAH infants with male external genitalia. After reviewing available literature, we conclude that because those extremely virlized 46,XX CAH patients who were reared male with healthy social support demonstrated satisfactory levels of social and sexual function as adults a male sex assignment should be considered in these types of infants when social and cultural environment are supportive.
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20
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Congenital adrenal hyperplasia: classification of studies employing psychological endpoints. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:191520. [PMID: 20976294 PMCID: PMC2952788 DOI: 10.1155/2010/191520] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 07/07/2010] [Accepted: 07/30/2010] [Indexed: 11/25/2022]
Abstract
Psychological outcomes in persons with congenital adrenal hyperplasia (CAH) have received substantial attention. The objectives of this paper were to (1) catalog psychological endpoints assessed in CAH outcome studies and (2) classify the conceptual/theoretical model shaping the research design and interpretation of CAH-related psychological effects. A total of 98 original research studies, published between 1955 and 2009, were categorized based on psychological endpoints examined as well as the research design and conceptual model guiding analysis and interpretation of data. The majority of studies (68%) investigated endpoints related to psychosexual differentiation. The preponderance of studies (76%) examined a direct relationship (i.e., inferring causality) between prenatal androgen exposure and psychological outcomes. Findings are discussed in relation to the observed imbalance between theoretical interest in the role of prenatal androgens in shaping psychosexual differentiation and a broader conceptual model that examines the role of other potential factors in mediating or moderating the influence of CAH pathophysiology on psychological outcomes in both affected females and males. The latter approach offers to identify factors amenable to clinical intervention that enhance both health and quality of life outcomes in CAH as well as other disorders of sex development.
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21
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Lee PA, Houk CP, Husmann DA. Should male gender assignment be considered in the markedly virilized patient With 46,XX and congenital adrenal hyperplasia? J Urol 2010; 184:1786-92. [PMID: 20728155 DOI: 10.1016/j.juro.2010.03.116] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE We assess the outcome in 46,XX men with congenital adrenal hyperplasia who were born with Prader 4 or 5 genitalia and assigned male gender at birth. MATERIALS AND METHODS After receiving institutional review board approval and subject consent we reviewed the medical records of 12 men 35 to 69 years old with 46,XX congenital adrenal hyperplasia, of whom 6 completed social and gender issue questionnaires. RESULTS All subjects were assigned male gender at birth, were diagnosed with virilizing congenital adrenal hyperplasia at age greater than 3 years and indicated a male gender identity with sexual orientation to females. Ten of the 12 subjects had always lived as male and 2 who were reassigned to female gender in childhood subsequently self-reassigned as male. Nine of the 12 men had long-term female partners, including 7 married 12 years or more. The 3 subjects without a long-term female partner included 1 priest, 1 who was reassigned female gender, married, divorced and self-reassigned as male, and 1 with a girlfriend and sexual activity. All except the priest and the subject who was previously married when female indicated a strong libido and frequent orgasmic sexual activity. Responses to self-esteem, masculinity, body image, social adjustment and symptom questionnaires suggested adjustments related to the extent of familial and social support. CONCLUSIONS Outcome data on severely masculinized 46,XX patients with congenital adrenal hyperplasia who were assigned male gender at birth indicate male gender identity in adulthood with satisfactory male sexual function in those retaining male genitalia. In men who completed questionnaires results were poorer in those lacking familial/social support. Male gender of rearing may be a viable option for parents whose children are born with congenital adrenal hyperplasia, a 46,XX karyotype and male genitalia, although positive parental and other support, and counseling are needed for adjustment.
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Affiliation(s)
- Peter A Lee
- Section of Pediatric Endocrinology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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22
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Nordenström A, Frisén L, Falhammar H, Filipsson H, Holmdahl G, Janson PO, Thorén M, Hagenfeldt K, Nordenskjöld A. Sexual function and surgical outcome in women with congenital adrenal hyperplasia due to CYP21A2 deficiency: clinical perspective and the patients' perception. J Clin Endocrinol Metab 2010; 95:3633-40. [PMID: 20466782 DOI: 10.1210/jc.2009-2639] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Females with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency are exposed to androgens during fetal development, resulting in virilization of the external genitalia. Little is known about how these women feel that the disease has affected their lives regarding surgery and psychosexual adaptation. OBJECTIVE Our objective was to investigate the correlation between the surgical results, the self-perceived severity of the disease, and satisfaction with sexual life and relate the results to the CYP21A2 genotype. DESIGN AND PARTICIPANTS Sixty-two Swedish women with CAH and age-matched controls completed a 120-item questionnaire, and a composite score for sexual function was constructed. The surgical outcome, including genital appearance and clitoral sensitivity, was evaluated by clinical examination. The patients were divided into four CYP21A2 genotype groups. RESULTS The sexual function score, but not for genital appearance, was higher in the patients satisfied with their sexual life. This was also true of the patients who were satisfied with the surgical result. There were discrepancies between the patients' perception of the impact of the condition on their sexual life and what health professionals would assume from clinical examination. The patients in the null genotype group scored lower on sexual function and satisfaction with their sexual life and had more surgical complications, also compared with the slightly less severe I2-splice genotype group. CONCLUSION Our data show that the null genotype group was considerably more affected by the condition than the other groups and should be regarded as a subgroup, both psychologically and from a surgical perspective. Genotyping adds clinically valuable information.
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Affiliation(s)
- Anna Nordenström
- Department of Pediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
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23
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Lee P, Houk C. Review of Outcome Information in 46,XX Patients with Congenital Adrenal Hyperplasia Assigned/Reared Male: What Does It Say about Gender Assignment? INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-982025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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24
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Gleeson HK, Wiley V, Wilcken B, Elliott E, Cowell C, Thonsett M, Byrne G, Ambler G. Two-year pilot study of newborn screening for congenital adrenal hyperplasia in New South Wales compared with nationwide case surveillance in Australia. J Paediatr Child Health 2008; 44:554-9. [PMID: 19012627 DOI: 10.1111/j.1440-1754.2008.01383.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To assess the benefits and practicalities of setting up a newborn screening (NBS) program in Australia for congenital adrenal hyperplasia (CAH) through a 2 year pilot screening in ACT/NSW and comparing with case surveillance in other states. METHODS The pilot newborn screening occurred between 1/10/95 and 30/9/97 in NSW/ACT. Concurrently, case reporting for all new CAH cases occurred through the Australian Paediatric Surveillance Unit (APSU) across Australia. Details of clinical presentation, re-sampling and laboratory performance were assessed. RESULTS 185,854 newborn infants were screened for CAH in NSW/ACT. Concurrently, 30 cases of CAH were reported to APSU, twelve of which were from NSW/ACT. CAH incidence was 1 in 15 488 (screened population) vs 1 in 18,034 births (unscreened) (difference not significant). Median age of initial notification was day 8 with confirmed diagnosis at 13(5-23) days in the screened population vs 16(7-37) days in the unscreened population (not significant). Of the 5 clinically unsuspected males in the screened population, one had mild salt-wasting by the time of notification, compared with salt-wasting crisis in all 6 males from the unscreened population. 96% of results were reported by day 10. Resampling was requested in 637 (0.4%) and median re-sampling delay was 11(0-28) days with higher resample rates in males (p < 0.0001). The within-laboratory cost per case of clinically unsuspected cases was A$42 717. CONCLUSION There seems good justification for NBS for CAH based on clear prevention of salt-wasting crises and their potential long-term consequences. Also, prospects exist for enhancing screening performance.
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Affiliation(s)
- Helena K Gleeson
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, New South Wales, Australia
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25
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Schreiner F, Brack C, Salzgeber K, Vorhoff W, Woelfle J, Gohlke B. False negative 17-hydroxyprogesterone screening in children with classical congenital adrenal hyperplasia. Eur J Pediatr 2008; 167:479-81. [PMID: 17516082 DOI: 10.1007/s00431-007-0505-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Accepted: 04/24/2007] [Indexed: 11/30/2022]
Abstract
We report 5 out of 214 children with classical congenital adrenal hyperplasia (CAH) that was not detected by neonatal 17-Hydroxyprogesterone screening. Therefore, diagnosis was only based on a suspect clinical picture and subsequent re-evaluation. In addition to 3 patients suffering from the simple virilizing form of CAH and not reported so far, the remaining 2 children whose CAH was missed by the screening suffered from the severe salt-wasting form. This report underlines the importance of a careful clinical investigation of newborns to detect signs of genital virilization. The differential diagnosis of classical CAH should be kept in mind even if neonatal screening is reported to be normal.
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Affiliation(s)
- Felix Schreiner
- Pediatric Endocrinology Division, Children's Hospital, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany.
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26
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Gupta DK, Shilpa S, Amini AC, Gupta M, Aggarwal G, Deepika G, Kamlesh K. Congenital adrenal hyperplasia: long-term evaluation of feminizing genitoplasty and psychosocial aspects. Pediatr Surg Int 2006; 22:905-9. [PMID: 16947028 DOI: 10.1007/s00383-006-1765-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Analyzing the long-term outcome in females with congenital adrenal hyperplasia (CAH) is crucial to evaluate effectiveness of treatment strategies. The aim of the study was to evaluate the long-term results in patients with CAH after feminizing surgery from the pediatric intersex clinic. Of 163 patients of CAH being followed (1980-2005), 50 responded for review. The patients had undergone feminizing genitoplasty and hormonal therapy. Evaluation included filling a detailed questionnaire along with physical examination and a structured interview in privacy. Assessment was performed for cosmetic results (50), psychosocial adjustment (42) above 5-year age, and functional outcome in 19 cases above 14-year age. Mean age at clitoroplasty was 3.6 years (1-16 years) and at time of the study was 14.6 years (4-23 years), with a mean post-op follow up of 6 years after the final surgery (6 months-17 years). The cosmetic outcome of clitoroplasty was excellent in 37, satisfactory in 10, and poor in 3. Gender identity was female, male, and mixed in 45, 4, and 1, respectively. The attitude to self and life was positive in 36 and negative in 6. The functional outcome of vaginoplasty was satisfactory, unsatisfactory, and undetermined in 11, 4, and 4, respectively. Endocrine control was satisfactory in 36/50. A novel assessment system has been adopted for analyzing the results of clitoroplasty and vaginoplasty. Endocrine control and surgical treatment are complimentary to each other to achieve satisfactory results in majority of CAH patients.
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Affiliation(s)
- D K Gupta
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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27
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Bin-Abbas BS, Sakati NA, Al-Ashwal AA. Gender identity in congenital adrenal hyperplasia secondary to 11-hydroxylase deficiency. Ann Saudi Med 2006; 26:239-41. [PMID: 16861857 PMCID: PMC6074433 DOI: 10.5144/0256-4947.2006.239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Bassam S Bin-Abbas
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
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28
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Dessens AB, Slijper FME, Drop SLS. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. ARCHIVES OF SEXUAL BEHAVIOR 2005; 34:389-97. [PMID: 16010462 DOI: 10.1007/s10508-005-4338-5] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This article reviews the literature on studies and case reports on gender identity and gender identity problems, gender dysphoria, and gender change in chromosomal females with congenital adrenal hyperplasia, raised male or female. The large majority (94.8%) of the patients raised female (N= 250) later developed a gender identity as girls and women and did not feel gender dysphoric. But 13 (5.2%) patients had serious problems with their gender identity. This percentage is higher than the prevalence of female-to-male transsexuals in the general population of chromosomal females. Among patients raised male, serious gender identity problems were reported in 4 (12.1%) out of 33 patients. From these observations, we conclude that the assignment to the female gender as a general policy for 46,XX patients with CAH appears justified, even in severely masculinized 46,XX newborns with CAH (Prader stage IV or V).
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MESH Headings
- Adrenal Hyperplasia, Congenital/complications
- Adrenal Hyperplasia, Congenital/psychology
- Adrenal Hyperplasia, Congenital/surgery
- Adult
- Chromosomes, Human, X
- Disorders of Sex Development/etiology
- Disorders of Sex Development/psychology
- Female
- Gender Identity
- Gonadal Dysgenesis, 46,XX/complications
- Gonadal Dysgenesis, 46,XX/psychology
- Gonadal Dysgenesis, 46,XX/surgery
- Humans
- Identification, Psychological
- Male
- Psychosexual Development
- Sex Characteristics
- Sex Factors
- Sexual Behavior
- Time Factors
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Affiliation(s)
- Arianne B Dessens
- Pediatrics Department, Division of Pediatric Endocrinology, Erasmus Medical Centre, Sophia Children's Hospital, Room SP-3435, POB 2060, 3000 CB, Rotterdam, The Netherlands.
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Abstract
The birth of a new baby is one of the greatest wonders of nature and one of the most exciting events known to man. The first question that is usually posed by the mother or father is "is it a boy or a girl?"; without this information the new parents cannot even formulate the second question which is usually "is he/she alright?". It is no wonder that the birth of a child with complex genital anomalies where the sex of rearing is uncertain at birth, presents difficult clinical and ethical issues.
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Affiliation(s)
- S F Ahmed
- Scottish Genital Anomaly Network, Scotland, UK.
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30
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Ozbey H, Darendeliler F, Kayserili H, Korkmazlar U, Salman T. Gender assignment in female congenital adrenal hyperplasia: a difficult experience. BJU Int 2004; 94:388-91. [PMID: 15291874 DOI: 10.1111/j.1464-410x.2004.04967.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report experience of gender (re)assignment in genotypic female (46XX) patients with congenital adrenal hyperplasia (f-CAH), a difficult and stressful experience if complicated with delayed presentation and inadvertent assignment. PATIENTS AND METHODS Between 1983 and 2002, 70 patients with f-CAH were counselled for gender assignment. The age at diagnosis and operation, the degree of virilization, parental consanguinity, the gender preference of the families, and the factors governing the decision-making process were determined. RESULTS Forty-one (59%) patients presented after the neonatal period. All parents had already assumed or were advised of a gender for their children, based on the suggestive appearance of the external genitalia. Consequently, 49 patients were reared as female and 21 as "male". Only nine of these "males" could be reassigned as females (mean age at presentation 7.87 months, sd 10.42). Twelve children had to be reared as "male"(mean age at presentation 55.8 months, sd 32.42) in compliance with the parents' and the study group's decision, and appropriate masculinizing reconstructive surgery was undertaken. The difference in the mean age of those reassigned as female and those who remained "male" was significant (P < 0.001). The parental consanguinity rate among the families was especially high in the 'male' patients. CONCLUSIONS It is extremely difficult to correct the gender of patients with f-CAH when they present at >2.5 years old. Furthermore, the delay in diagnosis and the male bias in choice of gender in our population might be a result of strong social pressures on families, influenced by cultural, traditional and economic factors.
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Affiliation(s)
- Hüsoyin Ozbey
- Department of Paediatric Endocrinology, Istanbul Medical Faculty, University of Istanbul, Turkey
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Abstract
PURPOSE OF REVIEW To elucidate recent findings regarding female puberty. The successful completion of puberty is a prerequisite for reproduction. Many later disorders of fertility and metabolism may develop during puberty. New more sensitive and specific assays provided us with possibilities for a better understanding of the process of puberty, and the discovery of new factors such as leptin evoked the hope of finding key regulators of the onset of puberty. RECENT FINDINGS The secular trend towards earlier menarche appears now to have come to an end, but discussions about changes in the age of pubertal onset still continue. In a few detected cases of leptin mutations puberty has not occurred spontaneously. The intact secretion of leptin seems to be a necessary prerequisite for the onset of puberty. Apart from that, recent research has indicated that leptin levels mainly reflect body composition. Leptin as well as gonadotropins, steroids and growth hormone shows specific circadian patterns. The 24 h pattern of leptin is similar before and after puberty, but the 24 h pattern of the other hormones changes. The serum concentration of inhibin B increases in the years preceding puberty and in early puberty, whereas inhibin A increases in mid to late puberty. SUMMARY The biological significance of the changing circadian patterns remains to be determined. Inhibin B serum concentrations together with follicle-stimulating hormone may indicate remaining potential ovarian activity during childhood in, for example, patients with Turner syndrome, but more information and other possible markers are needed.
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Affiliation(s)
- Dan Apter
- The Sexual Health Clinic, Family Federation of Finland and Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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