How common is intersex? a response to Anne Fausto-Sterling

The need for creation of new learning outcomes in core curricula publications on differences in sex development and transgender anatomy

Despite recognition that sex is a spectrum there are no learning outcomes in the Anatomical Society's Core Curricula that effectively deal with the anatomy of differences in sex development or the anatomy of transgender individuals who have undergone gender affirming surgery. We believe this is a gap that needs to be plugged urgently. Particularly in relation to healthcare students the consequence of perpetuating the stereotype of sexual dimorphism as a norm could marginalise these communities of patients even further. We believe that action in the form of a Delphi process to create new outcomes can be a first step in creating change that will lead to a more inclusive anatomy education.

Occupational Preferences, Childhood Behavior, and Openness: The Role of Sex, Sexual Orientation, and Gender Identity in Iran

Previous research suggests that both same-sex attraction and the personality trait "openness" are associated with sex-atypical preferences and behaviors. Here, we examined the links between adulthood occupational preferences, childhood play behavior, and openness among Iranian cisgender gynephilic males (n = 228), cisgender ambiphilic males (n = 48), cisgender androphilic males (n = 178), transgender androphilic males (n = 58), cisgender androphilic females (n = 226), cisgender ambiphilic females (n = 94), cisgender gynephilic females (n = 31), and transgender gynephilic females (n = 121) from Iran. Cisgender and transgender same-sex attracted males and females exhibited sex-atypical occupational preferences with the latter group showing even more sex-atypicality than the former. The personality trait openness did not differ between cisgender groups. Transgender androphilic males had a significantly higher mean score for openness compared to cisgender androphilic females and transgender gynephilic females, whereas transgender gynephilic females had a significantly lower mean score compared to cisgender androphilic males. In both males and females, childhood sex-atypicality, same-sex attraction, and openness were associated with sex-atypical occupational preferences. Our findings from Iran provides cross-cultural support for interconnectedness of childhood and adulthood sex-atypicality, openness, and same-sex attraction in males and females who are cisgender and transgender.

Association of Recalled Childhood Sex-Typed Behavior with Sexual Orientation and Gender Identity in Iranian Adult Males and Females

Same-sex sexual attraction in both males and females has been associated with childhood sex-atypical behavior. Gynephilic females recall behaving in a manner that is less female-typical and more male-typical compared to cisgender androphilic females, whereas androphilic males recall behaving in a manner that is less male-typical and more female-typical compared to cisgender gynephilic males. In addition, male and female ambiphilic individuals exhibit intermediate levels of childhood sex-atypicality. In this study, we examined recalled childhood sex-typed behavior among Iranian cisgender gynephilic males (n = 236), cisgender ambiphilic males (n = 51), cisgender androphilic males (n = 191), transgender androphilic males (n = 60), cisgender androphilic females (n = 243), cisgender ambiphilic females (n = 96), cisgender gynephilic females (n = 32), and transgender gynephilic females (n = 122). Both cisgender androphilic males and cisgender gynephilic females recalled elevated childhood sex-atypicality, scoring intermediate between cisgender gynephilic males and cisgender androphilic females. Male and female ambiphilic participants scored intermediate between their other- and same-sex attracted cisgender counterparts. Transgender androphilic males exhibited hyper-feminized childhood behavior, scoring even more female-typical than cisgender androphilic females. Transgender gynephilic females recalled behaving as male-typical as cisgender gynephilic males. Consistent with previous research, our findings from Iran - a non-Western, Middle Eastern culture - provide cross-cultural support for the universality of childhood sex-atypicality as a normative developmental precursor of monosexual or ambisexual same-sex attraction in both males and females who are cisgender and transgender.

No Bones About It: Sex Is Binary

Anthropologists have led the way in formulating techniques that reveal skeletal differences between males and females. Understanding of physical differences in the pelvis related to childbirth, hormonal impacts on bones, and extensive comparative studies have provided anthropologists with an array of traits and measurements that help them estimate sex using just bones. Forensic anthropologists and bioarcheologists are improving their ability to differentiate males and females by increasing research on a variety of postcranial bones and through the use of molecular data, especially new methods called proteomics, to identify sex in prepubescent juveniles. As remains from more cultures and time periods are studied, sex identification will continue to improve, because skeletal sex differences are in large part biologically determined. Yet, anthropologists have also been at the forefront of arguing that sex lies on a spectrum. Anthropologists who view sex as on a spectrum may deter sex identification progress; from their perspective, an individual of an undetermined sex may just be a nonbinary individual. Anthropologists who consider sex is on a spectrum are coming to this conclusion in part because they are looking for anatomical ideals, mistaking pathology for variation, and confusing independent variables with dependent variables. Nonetheless, anthropologists need to continue to improve sex identification techniques to reconstruct the past accurately, which may reveal less strict sex roles than previously presumed and help with the identification of crime victims. Forensic anthropologists should also increase their efforts to identify whether individuals have undergone medical procedures intended to change one's gender due to the current rise in transitioning individuals.

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.

The study of a hermaphroditic sheep caused by a mutation in the promoter of SRY gene

In mammals, sex-determining region Y (SRY) gene plays vital role as a transcription factor to regulate the expression of the genes contributing to development of male genitals. Any mutation disrupting expression of SRY gene can cause disorders of sex development (DSDs). In this study, the examination of a hermaphroditic (female-like) Shal sheep which was referred for infertility is described. Initially, the reproductive system of the sheep was histologically and anatomically assessed. Karyotyping was used to determine the real gender of the animal. Sex hormones including progesterone, estradiol, and testosterone were measured by enzyme-linked immunosorbent assay (ELISA). Eventually, promoter part and SRY gene were sequenced and aligned to detect any potential mutation using NCBI data base. Although anatomical inspection led to identification of uterus, ovary, and enlarged clitoris as well as testes in the sheep, the karyotyping results interestingly revealed that the animal was genetically a male. Although the sheep had both male and female gonads, there were no overt signs of reproductive behavior and gamete production was not observed. Plasma steroid hormone levels were reported to be at basal levels. Additionally, a mutation was detected on the promoter of the SRY gene. In conclusion, the case implies that mutation on the promoter part of SRY gene could disrupt sexual development of the fetus culminating in DSDs in the sheep.

The Participation of Trans Women in Competitive Fencing and Implications on Fairness: A Physiological Perspective Narrative Review

Debate has surrounded whether the participation of trans women in female sporting categories is fair, specifically the retained male physiological advantage due to increased testosterone compared to cisgender females. Recently, individual sporting organisations have been investigating and assessing policies regarding trans women athlete participation in female categories, resulting in several banning participation. This review aims to discuss the scientific evidence and provide appropriate guidance for the inclusion of trans women in elite competitive female fencing categories. Fencing is an intermittent sport, where competitions can span 1 to 3 days. The lunge is the most common movement used to attack opponents, where a successful hit relies on the speed of the action. Male puberty induced increased circulating testosterone promotes a greater stature, cardiovascular function, muscle mass, and strength compared to cisgender females, culminating in a ~12-40% sport performance advantage. Elite cisgender male fencers perform significantly higher, ~17-30%, jump heights and leg power measures compared to elite cisgender female fencers, resulting in faster lunges. Trans women receiving androgen-suppression therapy for 12 months showed significant reductions in strength, lean body mass, and muscle surface area, but even after 36 months, the measurements of these three indices remained above those for cisgender females. Previous male muscle mass and strength can be retained through continuation of resistance training. The literature reviewed shows that there is a retained physiological advantage for trans women who have undergone male puberty when participating in the elite competitive female fencing category. A proposed solution of an open or third gender category for elite fencing competition promotes fair competition, while allowing trans women to compete in their chosen sport.

"Intersex" Does not Violate the Sex Binary

This article supplements Julio Tuleda, Enrique Burguete, and Justo Aznar's "The Vatican opinion on gender theory" (Linacre). It supplements their article by providing a stronger argument for the thesis that "intersex" does not violate binary sex in human beings. In their response to Timothy F. Murphy's criticism of "the Vatican's" (rightfully corrected as the Magisterium of the Catholic Church's) position on the sex binary, they argue subsidiarily that "intersex" does not violate the sex binary. However, their argument against Murphy as stated is implausible; however, I provide a much stronger argument for their conclusion that intersex does not violate the sex binary. I intend to perform this supplementation in two stages, assuming the reader's familiarity with "The Vatican opinion on gender theory." First, I provide a broader background than Murphy's to the challenge that "intersex" conditions violate the sex binary, showing both how Murphy's criticism is unoriginal and how "intersex" both has been, and continues to be, misunderstood. Second, I problematize Tuleda's argument, and offer the strongest argument for the conclusion that "intersex" does not violate the sex binary on purely secular/nonreligious grounds (addressing Murphy's complaint). I conclude that the Magisterium of the Catholic Church remains correct that sex is binary.

Summary

Julio Tuleda, Enrique Burguete, and Justo Aznar's "The Vatican opinion on gender theory" challenges Timothy Murphy's criticism of sex binarism as endorsed by the Catholic Church. This article strengthens their criticism by focusing on "intersex" conditions.

Genetic control of typical and atypical sex development

Sex development relies on the sex-specific action of gene networks to differentiate the bipotential gonads of the growing fetus into testis or ovaries, followed by the differentiation of internal and external genitalia depending on the presence or absence of hormones. Differences in sex development (DSD) arise from congenital alterations during any of these processes, and are classified depending on sex chromosomal constitution as sex chromosome DSD, 46,XY DSD or 46,XX DSD. Understanding the genetics and embryology of typical and atypical sex development is essential for diagnosing, treating and managing DSD. Advances have been made in understanding the genetic causes of DSD over the past 10 years, especially for 46,XY DSD. Additional information is required to better understand ovarian and female development and to identify further genetic causes of 46,XX DSD, besides congenital adrenal hyperplasia. Ongoing research is focused on the discovery of further genes related to typical and atypical sex development and, therefore, on improving diagnosis of DSD.

Additional evidence for the role of chromosomal imbalances and SOX8, ZNRF3 and HHAT gene variants in early human testis development

BACKGROUND

Forty-six ,XY Differences/Disorders of Sex Development (DSD) are characterized by a broad phenotypic spectrum ranging from typical female to male with undervirilized external genitalia, or more rarely testicular regression with a typical male phenotype. Despite progress in the genetic diagnosis of DSD, most 46,XY DSD cases remain idiopathic.

METHODS

To determine the genetic causes of 46,XY DSD, we studied 165 patients of Tunisian ancestry, who presented a wide range of DSD phenotypes. Karyotyping, candidate gene sequencing, and whole-exome sequencing (WES) were performed.

RESULTS

Cytogenetic abnormalities, including a high frequency of sex chromosomal anomalies (85.4%), explained the phenotype in 30.9% (51/165) of the cohort. Sanger sequencing of candidate genes identified a novel pathogenic variant in the SRY gene in a patient with 46,XY gonadal dysgenesis. An exome screen of a sub-group of 44 patients with 46,XY DSD revealed pathogenic or likely pathogenic variants in 38.6% (17/44) of patients.

CONCLUSION

Rare or novel pathogenic variants were identified in the AR, SRD5A2, ZNRF3, SOX8, SOX9 and HHAT genes. Overall our data indicate a genetic diagnosis rate of 41.2% (68/165) in the group of 46,XY DSD.

Preparing Students to Deliver Care to Diverse Populations

The purpose of this study was to increase student exposure to diverse patients using patient ID cards in problem-based learning (PBL) at Case Western Reserve University (CWRU). The pre-clerkship curriculum capitalizes on facilitated small-group, case-based discussions to promote inquiry and learning of the foundational sciences. Quantitative and qualitative results supported a finding of added value to case-discussions and the humanization of case-patients. The inclusion of the patient ID cards resulted in most students indicating that it helped them learn about and prepare to care for their future population of diverse patients. The patient ID cards will allow us to develop specific learning objectives about the demographics to increase learning about diverse patient care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01648-0.

A Single-Center, Observational Study of 607 Children and Young People Presenting With Differences of Sex Development (DSD)

Context

Differences of sex development (DSD) represent a wide range of conditions presenting at different ages to various health professionals. Establishing a diagnosis, supporting the family, and developing a management plan are important.

Objective

We aimed to better understand the presentation and prevalence of pediatric DSD.

Methods

A retrospective, observational cohort study was undertaken in a single tertiary pediatric center of all children and young people (CYP) referred to a DSD multidisciplinary team over 25 years (1995-2019). In total, 607 CYP (520 regional referrals) were included. Data were analyzed for diagnosis, sex-assignment, age and mode of presentation, additional phenotypic features, mortality, and approximate point prevalence.

Results

Among the 3 major DSD categories, sex chromosome DSD was diagnosed in 11.2% (68/607) (most commonly 45,X/46,XY mosaicism), 46,XY DSD in 61.1% (371/607) (multiple diagnoses often with associated features), while 46,XX DSD occurred in 27.7% (168/607) (often 21-hydroxylase deficiency). Most children (80.1%) presented as neonates, usually with atypical genitalia, adrenal insufficiency, undescended testes or hernias. Those presenting later had diverse features. Rarely, the diagnosis was made antenatally (3.8%, n = 23) or following incidental karyotyping/family history (n = 14). Mortality was surprisingly high in 46,XY children, usually due to complex associated features (46,XY girls, 8.3%; 46,XY boys, 2.7%). The approximate point prevalence of neonatal referrals for investigation of DSD was 1 in 6347 births, and 1 in 5101 overall throughout childhood.

Conclusion

DSD represent a diverse range of conditions that can present at different ages. Pathways for expert diagnosis and management are important to optimize care.

Reaching the "Hard-to-Reach" Sexual and Gender Diverse Communities for Population-Based Research in Cancer Prevention and Control: Methods for Online Survey Data Collection and Management

PURPOSE

Around 5% of United States (U.S.) population identifies as Sexual and Gender Diverse (SGD), yet there is limited research around cancer prevention among these populations. We present multi-pronged, low-cost, and systematic recruitment strategies used to reach SGD communities in New Mexico (NM), a state that is both largely rural and racially/ethnically classified as a "majority-minority" state.

METHODS

Our recruitment focused on using: (1) Every Door Direct Mail (EDDM) program, by the United States Postal Services (USPS); (2) Google and Facebook advertisements; (3) Organizational outreach via emails to publicly available SGD-friendly business contacts; (4) Personal outreach via flyers at clinical and community settings across NM. Guided by previous research, we provide detailed descriptions on using strategies to check for fraudulent and suspicious online responses, that ensure data integrity.

RESULTS

A total of 27,369 flyers were distributed through the EDDM program and 436,177 impressions were made through the Google and Facebook ads. We received a total of 6,920 responses on the eligibility survey. For the 5,037 eligible respondents, we received 3,120 (61.9%) complete responses. Of these, 13% (406/3120) were fraudulent/suspicious based on research-informed criteria and were removed. Final analysis included 2,534 respondents, of which the majority (59.9%) reported hearing about the study from social media. Of the respondents, 49.5% were between 31-40 years, 39.5% were Black, Hispanic, or American Indian/Alaskan Native, and 45.9% had an annual household income below $50,000. Over half (55.3%) were assigned male, 40.4% were assigned female, and 4.3% were assigned intersex at birth. Transgender respondents made up 10.6% (n=267) of the respondents. In terms of sexual orientation, 54.1% (n=1371) reported being gay or lesbian, 30% (n=749) bisexual, and 15.8% (n=401) queer. A total of 756 (29.8%) respondents reported receiving a cancer diagnosis and among screen-eligible respondents, 66.2% reported ever having a Pap, 78.6% reported ever having a mammogram, and 84.1% reported ever having a colonoscopy. Over half of eligible respondents (58.7%) reported receiving Human Papillomavirus vaccinations.

CONCLUSION

Study findings showcase effective strategies to reach communities, maximize data quality, and prevent the misrepresentation of data critical to improve health in SGD communities.

Reaching the "Hard-to-Reach" Sexual and Gender Diverse Communities for Population-Based Research in Cancer Prevention and Control: Methods for Online Survey Data Collection and Management

Purpose

Around 5% of United States (U.S.) population identifies as Sexual and Gender Diverse (SGD), yet there is limited research around cancer prevention among these populations. We present multi-pronged, low-cost, and systematic recruitment strategies used to reach SGD communities in New Mexico (NM), a state that is both largely rural and racially/ethnically classified as a "majority-minority" state.

Methods

Our recruitment focused on using: (1) Every Door Direct Mail (EDDM) program, by the United States Postal Services (USPS); (2) Google and Facebook advertisements; (3) Organizational outreach via emails to publicly available SGD-friendly business contacts; (4) Personal outreach via flyers at clinical and community settings across NM. Guided by previous research, we provide detailed descriptions on using strategies to check for fraudulent and suspicious online responses, that ensure data integrity.

Results

A total of 27,369 flyers were distributed through the EDDM program and 436,177 impressions were made through the Google and Facebook ads. We received a total of 6,920 responses on the eligibility survey. For the 5,037 eligible respondents, we received 3,120 (61.9%) complete responses. Of these, 13% (406/3120) were fraudulent/suspicious based on research-informed criteria and were removed. Final analysis included 2,534 respondents, of which the majority (59.9%) reported hearing about the study from social media. Of the respondents, 49.5% were between 31-40 years, 39.5% were Black, Hispanic, or American Indian/Alaskan Native, and 45.9% had an annual household income below $50,000. Over half (55.3%) were assigned male, 40.4% were assigned female, and 4.3% were assigned intersex at birth. Transgender respondents made up 10.6% (n=267) of the respondents. In terms of sexual orientation, 54.1% (n=1371) reported being gay or lesbian, 30% (n=749) bisexual, and 15.8% (n=401) queer. A total of 756 (29.8%) respondents reported receiving a cancer diagnosis and among screen-eligible respondents, 66.2% reported ever having a Pap, 78.6% reported ever having a mammogram, and 84.1% reported ever having a colonoscopy. Over half of eligible respondents (58.7%) reported receiving Human Papillomavirus vaccinations.

Conclusion

Study findings showcase effective strategies to reach communities, maximize data quality, and prevent the misrepresentation of data critical to improve health in SGD communities.

Construction of Copy Number Variation Map Identifies Small Regions of Overlap and Candidate Genes for Atypical Female Genitalia Development

Copy number variations (CNVs) have been implicated in various conditions of differences of sexual development (DSD). Generally, larger genomic aberrations are more often considered disease-causing or clinically relevant, but over time, smaller CNVs have been associated with various forms of DSD. The main objective of this study is to identify small CNVs and the smallest regions of overlap (SROs) in patients with atypical female genitalia (AFG) and build a CNV map of AFG. We queried the DECIPHER database for recurrent duplications and/or deletions detected across the genome of AFG individuals. From these data, we constructed a chromosome map consisting of SROs and investigated such regions for genes that may be associated with the development of atypical female genitalia. Our study identified 180 unique SROs (7.95 kb to 45.34 Mb) distributed among 22 chromosomes. The most SROs were found in chromosomes X, 17, 11, and 22. None were found in chromosome 3. From these SROs, we identified 22 genes as potential candidates. Although none of these genes are currently associated with AFG, a literature review indicated that almost half were potentially involved in the development and/or function of the reproductive system, and only one gene was associated with a disorder that reported an individual patient with ambiguous genitalia. Our data regarding novel SROs requires further functional investigation to determine the role of the identified candidate genes in the development of atypical female genitalia, and this paper should serve as a catalyst for downstream molecular studies that may eventually affect the genetic counseling, diagnosis, and management of these DSD patients.

Understanding the Magnitude of Psychological Differences Between Women and Men Requires Seeing the Forest and the Trees

Whether women and men are psychologically very similar or quite different is a contentious issue in psychological science. This article clarifies this issue by demonstrating that larger and smaller sex/gender differences can reflect differing ways of organizing the same data. For single psychological constructs, larger differences emerge from averaging multiple indicators that differ by sex/gender to produce scales of a construct’s overall typicality for women versus men. For example, averaging self-ratings on personality traits more typical of women or men yields much larger sex/gender differences on measures of the femininity and masculinity of personality. Sex/gender differences on such broad-gauge, thematic variables are large relative to differences on their component indicators. This increased effect magnitude for aggregated scales reflects gains in both their reliability and validity as indicators of sex/gender. In addition, in psychological domains such as vocational interests that are composed of many variables, at least some of which differ by sex/gender, the multivariate distance between women and men is typically larger than the differences on the component variables. These analyses encourage recognition of the interdependence of sex/gender similarity and difference in psychological data.

DSDatlas: disorders of sex development atlas for reproductive endocrinology-related gene discovery in integrative omics platforms

OBJECTIVE

To facilitate the identification of related genes and candidate biomarkers for disorders of sex development (DSD), we present disorders of sex development atlas (http://dsd.geneworks.cn). Disorders of sex development are a spectrum of endocrine diseases with distinct mutations of genes or chromosomes, but several issues regarding their pathogenesis remain elusive. High-throughput methods have allowed genomic and transcriptomic analyses of DSD; however, these data are deposited in various repositories owing to a lack of integrated online resources.

DESIGN

A descriptive study of a specialized gene discovery platform designed for DSD.

SETTING

Publicly available DSD omics datasets and self-produced datasets.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The gene ranking result, with detailed information based on DSD terms in a gene-disease association knowledge base, and results of differential gene expression and mutation analyses from omics datasets.

RESULT(S)

The disorders of sex development atlas maintains both a knowledgebase for ranking DSD candidate genes and a database for DSD-related omics data analysis and visualization. We included 4 dominant classes of DSD in the knowledgebase: 15 subclasses and 44 specific disease names. Construction of the knowledgebase was centered upon Phenolyzer, with add-on seed gene databases customized by DSD-related genes collected from MalaCards, GeneCards, and DisGeNET. For the database, 25 experimental datasets related to DSD were integrated, including 24 public datasets from Gene Expression Omnibus and Sequence Read Archive and 1 self-generated dataset. A total of 474 samples from 240 DSD samples were collected for the database.

CONCLUSION(S)

This platform provides a friendly interface that integrates flexible and comprehensive analysis tools for differential expression and gene mutations between the DSD groups and controls.

Lifespan healthcare transitions among individuals with intersex traits in Canada: a mixed-methods and qualitative study

OBJECTIVES

To: (1) complete an integrative literature review of transition studies that focus on individuals with intersex traits; (2) conduct an environmental scan of the current resources (practice guidelines, policies and procedures) used by healthcare providers working with Canadians with intersex traits; (3) investigate the experiences of Canadians with intersex traits in their healthcare transitions across the lifespan and (4) assess the understanding of healthcare providers about these transitions.

DESIGN

A qualitative prospective community participation study was conducted. It used mixed methods including an environmental scan and semistructured engagement sessions.

SETTING

The environmental scan examined resources available throughout Canada. The engagement sessions took place in British Columbia and Ontario, Canada.

PARTICIPANTS

Sixteen participants were recruited. These included 13 individuals with intersex traits (a heterogeneous group of congenital conditions affecting the development of sex characteristics) and three caregivers.

METHODS

Mixed methods included an integrated literature review, environmental scan and qualitative approaches developed in collaboration with community partners.

RESULTS

The literature review identified gaps in transition care for individuals with intersex traits. The environmental scan uncovered no specific resources used by healthcare providers working with patients with intersex traits, though several general guidelines were used. Engaging providers in the study was problematic. Thematic analysis generated three main themes that emerged from the engagement sessions: (1) transition is a lifespan activity; (2) building personal agency is valuable and (3) well-being promotion is an application of health literacy.

CONCLUSIONS

Transition resources for individuals living in Canada with intersex are scarce. Transitions happen across the lifespan with ownership of thought and actions seen as acts of personal agency. Health literacy skills and knowledge change with increased age, yet the primary source of knowledge often remained important in the individual's autobiographical self.

The Erasure of Intersex, Transgender, Nonbinary, and Agender Experiences Through Misuse of Sex and Gender in Health Research

Conflation of the terms and concepts of "sex" and "gender" continues to perpetuate the invisibility of sex and gender minorities and obscure information about the ways in which biological sex and gender affect health. The misuse of sex and gender terms and the sex and gender binaries can yield inaccurate results but also, more importantly, contributes to the erasure of intersex, transgender, nonbinary, and agender health experiences. In this article, we discuss ways in which public health researchers can use sex and gender terms correctly and center the health experiences of intersex, transgender, nonbinary, and agender individuals. This includes promoting sensitivity in approaching sex and gender minority communities, improving survey questions, and collaborating with GSM communities to improve research quality and participant experiences. Improving our standards for the quality of sex and gender term usage and centering sex and gender minorities in public health research are imperative to addressing the health inequalities faced by sex and gender minorities.

The Effects of Gender Trouble: An Integrative Theoretical Framework of the Perpetuation and Disruption of the Gender/Sex Binary

In the Western world, gender has traditionally been viewed as binary and as following directly from biological sex. This view is slowly changing among both experts and the general public, a change that has been met with strong opposition. In this article, we explore the psychological processes underlying these dynamics. Drawing on previous work on gender performativity as well as gender as a performance, we develop a psychological framework of the perpetuation and disruption of the gender/sex binary on a stage that facilitates and foregrounds binary gender/sex performance. Whenever character, costume, and script are not aligned the gender/sex binary is disrupted and gender trouble ensues. We integrate various strands of the psychological literature into this framework and explain the processes underlying these reactions. We propose that gender trouble can elicit threat-personal threat, group-based and identity threat, and system threat-which in turn leads to efforts to alleviate this threat through the reinforcement of the gender/sex binary. Our framework challenges the way psychologists have traditionally treated gender/sex in theory and empirical work and proposes new avenues and implications for future research.

Role of cross-campus multidisciplinary team meetings in decision-making for children and adolescents with differences of sex development/intersex

AIM

Management of children with differences/disorders of sex development (DSD) is complex with limited evidence to guide clinical decisions. Regular multidisciplinary team meetings were set up in Sydney and Melbourne paediatric hospitals to enable systematic peer review of complex decision-making. We aim to describe the workload and role of these meetings.

METHODS

The multidisciplinary team forum includes invited representatives from endocrinology, urology, gynaecology, genetics, psychology, social work, clinical ethics, laboratory and hospital executive and meetings occur 1-3 times monthly. Descriptive data were collected from de-identified meeting referrals and minutes between August 2012 to August 2018 (Sydney) and January 2014 to August 2018 (Melbourne).

RESULTS

A total of 192 referrals (142 new and 50 follow-ups) aged 1 week to 17 years were discussed across the two sites. 46, XY DSD (n = 81) was the most common sub-classification. Consideration of surgical options and optimal management of gonads with malignant potential were amongst the common reasons for referral to the multidisciplinary team meetings. Surgical interventions were considered but not recommended after review for 38 of 154 (24.7%) procedures. Gonad retention to allow potential functional benefit was recommended in 15/46 (32.6%) referrals. Evidence of premalignant or malignant changes was found in 20/57 (35%) gonads removed, with dysgenetic features and atrophy/streak features in 6 (10.5%) and 27 (47.4%) gonads respectively.

CONCLUSION

Formal DSD multidisciplinary team meetings provide a framework and opportunity for multi and interdisciplinary discussions amongst representatives from several specialities to help make complex decision-making.

A fish with no sex: gonadal and adrenal functions partition between zebrafish NR5A1 co-orthologs

People with NR5A1 mutations experience testicular dysgenesis, ovotestes, or adrenal insufficiency, but we do not completely understand the origin of this phenotypic diversity. NR5A1 is expressed in gonadal soma precursor cells before expression of the sex-determining gene SRY. Many fish have two co-orthologs of NR5A1 that likely partitioned ancestral gene subfunctions between them. To explore ancestral roles of NR5A1, we knocked out nr5a1a and nr5a1b in zebrafish. Single-cell RNA-seq identified nr5a1a-expressing cells that co-expressed genes for steroid biosynthesis and the chemokine receptor Cxcl12a in 1-day postfertilization (dpf) embryos, as does the mammalian adrenal-gonadal (interrenal-gonadal) primordium. In 2dpf embryos, nr5a1a was expressed stronger in the interrenal-gonadal primordium than in the early hypothalamus but nr5a1b showed the reverse. Adult Leydig cells expressed both ohnologs and granulosa cells expressed nr5a1a stronger than nr5a1b. Mutants for nr5a1a lacked the interrenal, formed incompletely differentiated testes, had no Leydig cells, and grew far larger than normal fish. Mutants for nr5a1b formed a disorganized interrenal and their gonads completely disappeared. All homozygous mutant genotypes lacked secondary sex characteristics, including male breeding tubercles and female sex papillae, and had exceedingly low levels of estradiol, 11-ketotestosterone, and cortisol. RNA-seq showed that at 21dpf, some animals were developing as females and others were not, independent of nr5a1 genotype. By 35dpf, all mutant genotypes greatly under-expressed ovary-biased genes. Because adult nr5a1a mutants form gonads but lack an interrenal and conversely, adult nr5a1b mutants lack a gonad but have an interrenal, the adrenal, and gonadal functions of the ancestral nr5a1 gene partitioned between ohnologs after the teleost genome duplication, likely owing to reciprocal loss of ancestral tissue-specific regulatory elements. Identifying such elements could provide hints to otherwise unexplained cases of Differences in Sex Development.

Social media engagement, perpetuating selected information, and accuracy regarding CA SB-201: Treatment or intervention on the sex characteristics of a minor

INTRODUCTION

Disorders/differences of sex development (DSD) is a medical term used to encompass patients born with congenital conditions that lead to atypical development of the genitalia and reproductive structures.

OBJECTIVE

To evaluate the factual accuracy of shared articles from popular social media platforms regarding the California State Bill, SB-201, Treatment or Intervention: Sex Characteristics of a Minor.

DESIGN

We used the BuzzSumo© search engine to analyze the terms "SB 201", "intersex," "DSD," and "surgery ban" for worldwide social media engagement (Facebook, Twitter, Pinterest, and Reedit) one month before and after bill introduction on January 31, 2019, and final hearing on January 13, 2020. Articles were categorized based on source, opinion of the author, accuracy of scientific information, use of term intersex versus disorder/difference of sex development (DSD), definition of intersex, advocacy group quoted, reference to surgical "gender assignment," mention of negative consequences of the bill/other banned surgeries, the definition of medical necessity, parental rights, psychosocial concerns, and photographic content.

RESULTS

Twenty unique articles with peak activity were analyzed. Eighteen were from news and two from editorial web sources. All mentioned SB-201.50% were classified as one-sided, meaning both arguments for and against were not presented. 60% of articles were perpetuating selected information correlating with the author's opinion. 65% of articles were misleading in terms of factual accuracy. All articles used the term intersex. 20% of articles used scientific terms such as atypical genitalia (2), DSD (2), and born with variations of sex characteristics (1). A urologist was quoted in 45% of articles, while 75% quoted intersex advocacy groups. 55% of articles referred to the surgeries as "gender normalizing," and 75% referred to "assigning gender". Three articles mentioned other non-DSD surgeries that SB-201 would ban in addition to any that "normalize appearance." 45% (9) included any definition of medical necessity, the most common being inability to urinate (7), which is incompatible with post-natal viability.

DISCUSSION

Our study demonstrates that some of the most disseminated information on social media surrounding the introduction and hearing of SB-201 that did not include input from the medical community, perpetuated selected information, and lacked appropriate factual content.

CONCLUSION

Misinformation in the media can be harmful to patients and the general public. This study highlights the need for balanced and accurate reporting on medical topics that can have emotional and political consequences when speaking to broader audiences.

Of Time Gals and Mega Men: Empirical Findings on Gender Differences in Digital Game Genre Preferences and the Accuracy of Respective Gender Stereotypes

We investigated the accuracy of gender stereotypes regarding digital game genre preferences. In Study 1, 484 female and male participants rated their preference for 17 game genres (gender differences). In Study 2, another sample of 226 participants rated the extent to which the same genres were presumably preferred by women or men (gender stereotypes). We then compared the results of both studies in order to determine the accuracy of the gender stereotypes. Study 1 revealed actual gender differences for most genres—mostly of moderate size. Study 2 revealed substantial gender stereotypes about genre preferences. When comparing the results from both studies, we found that gender stereotypes were accurate in direction for most genres. However, they were, to some degree, inaccurate in size: For most genres, gender stereotypes overestimated the actual gender difference with a moderate mean effect size.

A large cohort of disorders of sex development and their genetic characteristics: 6 novel mutations in known genes

INTRODUCTION

Disorders of sex development (DSD) constitutes a group of congenital conditions that affect urogenital differentiation and are associated with chromosomal, gonadal and phenotypic sex abnormalities.

OBJECTIVE

To evaluate the clinical and genetic features of childhood DSD cases.

MATERIALS AND METHODS

DSD patients followed up between the years of 2002-2018 were evaluated in terms of their complaints, demographic, clinical features and genetic diagnoses.

RESULTS

Out of 289 patients, 143(49.5%) were classified as 46XY DSD, 62(21.5%) as 46XX DSD and 84(29%) as sex chromosomal DSD. Genetic diagnosis was achieved in 150 patients (51.9%). The distribution of the molecular diagnosis of the 46XY DSD patients were; 12 (26.6%) SRD5A2, 10 (22.2%) AR, 7 (15.5%) HSD17B3, 3 (6.6%) WT-1, 2 (4.4%) AMHR2, 2 (4.4%) AMH, 2 (4.4%) LHCGR, 2 (4.4%) HSD3B2, 1 (2.2%) NR5A1, 1 (2.2%) CYP17A1 and 1 (2.2%) SRY mutation. Fifty (80.6%) of the 46XX DSD patients received a diagnosis with clinical and laboratory findings. Twenty-four (38.7%) of them were 21-hydroxylase deficiency, 9(14.5%) Rokitansky-Küster-Hauser Syndrome, 4 (6.5%) 11-β hydroxylase deficiency, 3 (4.8%) gonadal dysgenesis and 2 (3.2%) aromatase deficiency. In 46XX group pathogenic mutations were detected in 21(33.8%) of the patients. Eighty-four (29%) patients were diagnosed as sex chromosomal disorder. Of these 66 (78.5%) were Turner Syndrome, 6 (7.2%) Klinefelter Syndrome and 10 (11.9%) mix gonadal dysgenesis. Gender re-assignment was decided in 11 patients. Malignant and pre-invasive lesions was diagnosed in 8 (2.7%) patients.

CONCLUSION

Many of DSD's are clinically similar and etiology of numerous of them still cannot be established. A multi-disciplinary approach and new rapid genetic diagnostic methods are needed in the process from diagnosis to gender assignment and follow-up.

Will comprehensive sexuality education (CSE) help in youth development?

Purpose

The purpose of this review is to critically analyse the extant research and help readers understand the ways the school-based comprehensive sexuality education (CSE) can contribute towards youth development and urge policymakers to implement nationwide good-quality, scientific, culturally relevant, age-appropriate and holistic school-based CSE.

Design/methodology/approach

This literature review has been designed using the extant information available on Google Scholar, Web of Science (WoS) and PubMed.

Findings

The findings of this review inform that there is a significant need amongst the youth of the day for good-quality, scientific, culturally relevant, age-appropriate and holistic school-based CSE. Also, the findings suggest that there are significant associations between school-based CSE and youth development.

Research limitations/implications

This research paper although draws from extant literature about sexuality education and its delivery across the globe, it applies the sexuality education scenario in India.

Practical implications

The findings of this review aim to implicate nationwide policy-level changes to implement CSE in the school curricula. There are more practical behavioural changes that CSE could foster amongst students, which are discussed in the review.

Social implications

Due to the behavioural changes that CSE could foster amongst students, it may help in the upbringing of responsible citizens who are free of health complications, who can make independent health-related decisions and look after each other in the community.

Originality/value

This review is an original contribution from the author. Whilst there is extant literature about CSE and youth development, this article fills the void by investigating the interdependent contributions that both the concepts can make to one another and encourages more research on this topic.

Gender Identity and Assignment Recommendations in Disorders of Sex Development Patients: 20 Years’ Experience and Challenges

OBJECTIVE

Gender assignment in infants and children with disorders of sex development (DSD) is a stressful situation for both patient/families and medical professionals.

METHODS

The purpose of this study was to investigate the results of gender assignment recommendations in children with DSD in our clinic from 1999 through 2019.

RESULTS

The mean age of the 226 patients with DSD at the time of first admission were 3.05±4.70 years. 50.9% of patients were 46,XY DSD, 42.9% were 46,XX DSD and 6.2% were sex chromosome DSD. Congenital adrenal hyperplasia (majority of patients had 21-hydroxylase deficiency) was the most common etiological cause of 46,XX DSD. In 46,XX patients, 87 of 99 (89.7%) were recommended to be supported as a female, 6 as a male, and 4 were followed up. In 46,XY patients, 40 of 115 (34.8%) were recommended to be supported as a female, and 70 as male (60.9%), and 5 were followed up. In sex chromosome DSD patients, 3 of 14 were recommended to be supported as a female, 9 as a male. The greatest difficulty in making gender assignment recommendations were in the 46,XY DSD group.

CONCLUSION

In DSD gender assignment recommendations, the etiologic diagnosis, psychiatric gender orientation, expectation of the family, phallus length and Prader stage were effective in the gender assignment in DSD cases, especially the first two criteria. It is important to share these experiences among the medical professionals who are routinely charged with this difficult task in multidisciplinary councils.

Survey of disorders of sex development in a large cohort of patients with diverse Mendelian phenotypes

Disorders of sex development (DSD) are congenital conditions with atypical development of chromosomal, gonadal, or anatomical sex. The estimated incidence ranges from 1 in 4,500-5,500 for strictly defined "ambiguous genitalia" to 1 in 300 or higher when a broader definition is implemented. In this study, we aim to define DSD phenotypes encountered in a large heterogeneous cohort of molecularly characterized Mendelian disorders in a single center. Data were retrieved for patients with documented abnormal genitalia based on the 2006 consensus criteria. Out of 149 patients (129 families) with compatible human phenotype ontology, 76 patients (68 families) had an identified genetic cause and were included in our analysis. Potentially causal variants were identified in 42 genes, and two patients had a dual molecular diagnosis. Six genes have no associated phenotype in OMIM (PIANP, CELSR2, USP2, FAM179B, TXNDC15, and CCDC96). Thirteen genes have non-DSD OMIM phenotypes, thus we are expanding their phenotype to include DSD. We also highlight how certain disorders are under-recognized despite their established DSD phenotype in OMIM, especially CTU2-related DREAM-PL syndrome and TSPYL1-related sudden infant death with dysgenesis of the testes syndrome. In conclusion, this study of a large heterogeneous Mendelian cohort expands the list of genes and disorders beyond those classically DSD-linked.

“Their Untold Stories…”: Lived Experiences of Being a Transgender (Hijra), A Qualitative Study From India

Background: Transgender is an umbrella term, used to encompass people who have a gender identity or gender expression, which differs from their sex assignment at birth. Being independent of sexual orientation, they have often been classified as the “third sex.” Based on various sociocultural traditions and beliefs, they are frequently “othered,” discriminated, and stigmatized against. This has led to their limited social inclusion and participation. In the social diversity of a populous country like India, transgenders are termed as “hijra’s,” belonging to a separate social community. Their experiences, perceptions, and unmet needs are rarely evaluated.

Methods: Qualitative approach was used to explore the “lived experience” of 4 individuals who are part of the “hijra” community in Kolkata. These individuals were born with ambiguous primary sex characteristics. In-depth interview was conducted with these participants with subsequent transcription. Interpretative phenomenological analysis (IPA) was used for analysis.

Results: A total of 2 superordinate themes (identity issues, relationship issues) and 6 subordinate themes emerged from the analysis (identification with feminine gender, perceptions regarding caregivers, perception regarding siblings, perception regarding childhood peer groups, identification with the hijra community, societal rejection). The findings have been discussed in terms of identity process, social and cultural construal of hijras in this part of the world.

Conclusion: In India, the transgenders (hijra community) represent a unique subculture besides the heterosexual groups. Understanding their relationships, sexuality and societal interactions are vital for their psychosocial well-being and related interventions. This study adds to the shared understanding of their marginalization and lived experiences, in their own voices.

Adrenoleukodystrophy Newborn Screening in the Netherlands (SCAN Study): The X-Factor

X-linked adrenoleukodystrophy (ALD) is a devastating metabolic disorder affecting the adrenal glands, brain and spinal cord. Males with ALD are at high risk for developing adrenal insufficiency or progressive cerebral white matter lesions (cerebral ALD) at an early age. If untreated, cerebral ALD is often fatal. Women with ALD are not at risk for adrenal insufficiency or cerebral ALD. Newborn screening for ALD in males enables prospective monitoring and timely therapeutic intervention, thereby preventing irreparable damage and saving lives. The Dutch Ministry of Health adopted the advice of the Dutch Health Council to add a boys-only screen for ALD to the newborn screening panel. The recommendation made by the Dutch Health Council to only screen boys, without gathering any unsolicited findings, posed a challenge. We were invited to set up a prospective pilot study that became known as the SCAN study (SCreening for ALD in the Netherlands). The objectives of the SCAN study are: (1) designing a boys-only screening algorithm that identifies males with ALD and without unsolicited findings; (2) integrating this algorithm into the structure of the Dutch newborn screening program without harming the current newborn screening; (3) assessing the practical and ethical implications of screening only boys for ALD; and (4) setting up a comprehensive follow-up that is both patient- and parent-friendly. We successfully developed and validated a screening algorithm that can be integrated into the Dutch newborn screening program. The core of this algorithm is the “X-counter.” The X-counter determines the number of X chromosomes without assessing the presence of a Y chromosome. The X-counter is integrated as second tier in our 4-tier screening algorithm. Furthermore, we ensured that our screening algorithm does not result in unsolicited findings. Finally, we developed a patient- and parent-friendly, multidisciplinary, centralized follow-up protocol. Our boys-only ALD screening algorithm offers a solution for countries that encounter similar ethical considerations, for ALD as well as for other X-linked diseases. For ALD, this alternative boys-only screening algorithm may result in a more rapid inclusion of ALD in newborn screening programs worldwide.

LEYDIG CELL HYPOPLASIA: A UNIQUE PARADOX IN THE DIAGNOSIS OF 46,XY DISORDERS OF SEX DEVELOPMENT

Objective

Disorders of sex development (DSD) are defined as conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female. Mutations in genes present in X, Y or autosomal chromosomes can cause abnormalities of testis determination or 46,XY DSD. Leydig cell hypoplasia (LCH), also known as Leydig cell agenesis, is a rare autosomal recessive endocrine syndrome of 46,XY DSD. Our objective here is to present the case of a 27-year-old, phenotypic female who presented with primary amenorrhea and later found to have LCH.

Methods

We used formatted history and clinical examination followed by necessary hormonal investigations. The diagnosis was confirmed by histopathology of resected testes and genetic mutation analysis.

Results

The patient's physical examination was unremarkable except 2 ovoid lumps present in the inguinovulvar region. There were no müllerian structures on sonography. Estrogen and both basal and stimulated testosterone levels were low whereas luteinizing hormone and follicle-stimulating hormone were high. Her chromosomal sex was found to be 46,XY. The histopathology of the resected inguinal lumps showed atrophic testicular change lacking Leydig cells with relative preservation of Sertoli cells. Genetic mutation analysis failed to reveal any significant aberration in the LHCGR gene. At present she is on estrogen replacement therapy having undergone bilateral orchidectomy and vaginoplasty.

Conclusion

LCH represents a unique example of diagnostic dilemma in gender identification. It requires a multidisciplinary approach for optimum outcome.

Evolving indications for surgical intervention in patients with differences/disorders of sex development: Implications of deferred reconstruction

Rare medical conditions are difficult to study due to the lack of patient volume and limited research resources, and as a result of these challenges, progress in the care of patients with these conditions is slow. Individuals born with differences of sex development (DSD) fall into this category of rare conditions and have additional social barriers due to the intimate nature of the conditions. There is also a lack of general knowledge in the medical community about this group of diverse diagnoses. Despite these limitations, progress has been made in the study of effective ways to care for patients who are born with chromosomal or anatomical differences of their internal reproductive organs or external genitalia. Advocacy groups have placed a spotlight on these topics and asked for a thoughtful approach to educate parents of newborns, medical providers, and the adolescents and young adults themselves as they mature.¹ There is growing interest in the approaches to surgical reconstruction of the genitalia and the management of internal gonads, specifically the timing of procedures and the indications for those procedures.² Advocates suggest deferring surgical procedures until the affected individual can participate in the decision-making process. This approach requires a roadmap for addressing the long-term implications of delayed surgical management. Presented here is a review of the specific issues regarding the complex management of the various categories of DSD.

Disorders of Sexual Development: Current Status and Progress in the Diagnostic Approach

Disorders of sexual development (DSD) are conditions with an atypical chromosomal, gonadal or phenotypic sex, which leads to differences in the development of the urogenital tract and different clinical phenotypes. Some genes have been implicated in the sex development during gonadal and functional differentiation where the maintenance of the somatic sex of the gonad as either male or female is achieved by suppression of the alternate route. The diagnosis of DSD requires a structured approach, involving a multidisciplinary team and different molecular techniques. We discuss the dimorphic genes and the specific pathways involved in gonadal differentiation, as well as new techniques for genetic analysis and their diagnostic value including epigenetic mechanisms, expanding the evidence in the diagnostic approach of individuals with DSD to increase knowledge of the etiology.

Disorders of sex development: Genetic characterization of a patient cohort

Disorders of sex development (DSDs) are congenital conditions in which the external appearance of the individual does not coincide with the chromosomal constitution or the gonadal sex. In other words, there is an ambiguous or intermediate condition between the male and female phenotypes of the anatomical sex. These atypical conditions are manifested in several ways, ranging from genital ambiguity to phenotypes that are so attenuated that they can go unnoticed or appear normal. Currently, there is a lack of understanding of the factors responsible for these outcomes; however, they are likely to be conditioned by genetic, hormonal and environmental factors during prenatal and postnatal development. The present study determined the genetic etiology of DSDs in Colombian patients by conventional cytogenetic analysis, FISH and MLPA (for SF1, DAX1, SOX9, SRY and WNT4). A cohort of 43 patients with clinical phenotypes of sex development disorder was used in the present study. Using this multistep experimental approach, a diagnostic percentage of 25.58% was obtained: 17 patients (39.53%) were classified as having gonadal development disorders, the majority of which were ovotesticular disorders with numerical and/or structural alterations of the sex chromosomes, 9 patients (20.93%) were classified as having testicular DSD with a 46,XY karyotype, and 3 patients (6.98%) as having ovarian DSD with a 46,XX karyotype. The remaining 14 patients (32.56%) were classified as 'other' since they could not be grouped into a specific class of gonadal development, corresponding to hypospadias and multiple congenital anomalies. These findings highlight the importance of histological and cytogenetic studies in a gonadal biopsy. In 11/43 cases, the multistep experimental protocol presented in the present study yielded etiological or histological findings that could be used to define the medical management of patients with DSDs. In conclusion, for the etiological diagnosis of DSDs, a broad‑spectrum approach that includes endocrinological tests, conventional karyotyping, molecular karyotyping by FISH and, molecular tests is required, in addition to gonadal tissue analyses, to identify genetic alterations.

Predictors of Psychosocial Distress in Parents of Young Children with Disorders of Sex Development

PURPOSE

We evaluated demographic, financial and support predictors of distress for parents of young children with disorders of sex development including atypical genital development, and characterized early parental experiences. This work extends our previous findings to identify those parents at risk for distress.

MATERIALS AND METHODS

Participants included mothers (76) and fathers (63) of a child (78) diagnosed with disorders of sex development characterized by moderate to severe genital atypia. Parents completed a demographic questionnaire, measures of anxious and depressive symptoms, quality of life, illness uncertainty and posttraumatic stress symptoms, and rated their satisfaction with the appearance of their child's genitalia.

RESULTS

Depressive and posttraumatic stress symptoms of caregivers were comparable to standardized norms while levels of anxious symptoms were below norms. A subset of parents reported clinically elevated symptoms. Overall 26% of parents reported anxious symptoms, 24% reported depressive symptoms and 17% reported posttraumatic stress symptoms. Levels of illness uncertainty were lower than those of parents of children with other chronic illnesses. Differences by parent sex emerged, with mothers reporting greater distress. Lower income, increased medical care and travel expenses, and having no other children were related to increased psychosocial distress.

CONCLUSIONS

Early psychosocial screening is recommended for parents of children with disorders of sex development. Clinicians should be aware that financial burden and lack of previous parenting experience are risk factors for distress.

Sex Assignment and Diagnostics in Infants with Ambiguous Genitalia - A Single-Center Retrospective Study

Ambiguous genitalia affect 1 in 5,000 live births. Diagnostic procedures can be time-consuming, and often the etiology cannot be established in this group of individuals with differences/disorders of sex development (DSD). We aimed to evaluate the clinical presentation, sex assignment, and diagnostic workup in these patients. In this retrospective observational study, we included infants who presented with ambiguous genitalia from 2006 to 2016 at the Radboudumc (Radboud University Medical Center) DSD expert center. Relevant data were collected from patient records. Sixty-two 46,XY and fourteen 46,XX individuals were included. Sex was assigned in the first days of life and based on the combination of presence or absence of a uterus on ultrasound, AMH level, palpable gonads, and the karyotype (corresponded in 96% of the patients). In 86% of the 46,XX DSD subjects, a diagnosis was made, whereas in only 15/62 (24%) of the 46,XY DSD individuals, etiology was determined. In 52 individuals, genetic testing was performed resulting in a diagnosis in 24 patients (46%). AMH, hCG-stimulated testosterone, and dihydrotestosterone levels contributed to determining etiology, whilst basal testosterone and basal dihydrotestosterone did not. Establishing a diagnosis in infants with ambiguous genitalia is complex and challenging; this study aids to enhance this process and improve current practice.

Disorders of sex development (DSD) web-based information: quality survey of DSD team websites

Objectives

Consumers rely on online health information, particularly for unusual conditions. Disorders of Sex Development (DSD) are complex with some aspects of care controversial. Accurate web-based DSD information is essential for decision-making, but the quality has not been rigorously evaluated. The purpose of the present study was to assess the quality of online health information related to DSD presented by 12 pediatric institutions comprising the NIH-sponsored DSD-Translational Research Network (DSD-TRN).

Methods

DSD-TRN sites identified team webpages, then we identified linked webpages. We also used each institution search engine to search common DSD terms. We assessed webpages using validated tools: the Simple Measure of Gobbledygook (SMOG) determined reading level, the Patient Education Materials Assessment Tool (PEMAT) evaluated content for understandability and actionability, and the DISCERN tool assessed treatment decision-making information (for hormone replacement and surgery). We developed a “Completeness” measure which assessed the presence of information on 25 DSD topics.

Results

The SMOG reading level of webpages was at or above high-school grade level. Mean (SD) PEMAT understandability score for Team Pages and Team Links was 68% (6%); on average these pages met less than 70% of the understandability criteria. Mean (SD) PEMAT actionability score was 23% (20%); few patient actions were identified. The DISCERN tool determined that the quality of information related to hormone treatment and to surgery was poor. Sites’ webpages covered 12–56% of the items on our Completeness measure.

Conclusions

Quality of DSD online content was poor, and would be improved by using a variety of strategies, such as simplifying word choice, using visual aids, highlighting actions patients can take and acknowledging areas of uncertainty. For complex conditions such as DSD, high-quality web-based information is essential to empower patients (and caregiver proxies), particularly when aspects of care are controversial.

Analytical Review of Contemporary Fatwas in Resolving Biomedical Issues Over Gender Ambiguity

Issues of gender ambiguity have been discussed over time from both Islamic and medical perspectives. In Islam, these issues are typically considered in the context of khunūthah (literally translated as hermaphroditism). While biomedical studies have appeared to provide a large amount of information on abnormal human biological development, i.e. Disorders of Sex Development (DSDs). However, the connection between these two fields has been given little attention. This research aims to determine the Islamic underpinnings through the fatwa around the globe. Thus, institutional fatwa organisations among Sunni schools of thought at the international, regional and national levels are observed. The fatwas regarding the management of individuals with gender ambiguity, not specifically on DSDs, are chosen and presented accordingly. Based on the findings, the sporadic fatwas from different parts of the world delineate the issue of sex ambiguity and seem to be able to provide general guidelines for management of Muslim patients with DSDs. Three common aspects have been discussed including the methodology of gender assignment, the decision-making process and the surgical and hormonal treatments.

Etiology and Clinical Presentation of Disorders of Sex Development in Kenyan Children and Adolescents

OBJECTIVE

The purpose of this study was to describe baseline data on etiological, clinical, laboratory, and management strategies in Kenyan children and adolescents with Disorders of Sex Development (DSD).

METHODS

This retrospective study included patients diagnosed with DSD who presented at ages 0-19 years from January 2008 to December 2015 at the Kenyatta National (KNH) and Gertrude's Children's (GCH) Hospitals. After conducting a search in the data registry, a structured data collection sheet was used for collection of demographic and clinical data. Data analysis involved description of the frequency of occurrence of various variables, such as etiologic diagnoses and patient characteristics.

RESULTS

Data from the records of 71 children and adolescents were reviewed at KNH (n = 57, 80.3%) and GCH (n = 14, 19.7%). The mean age at the time of diagnosis was 2.7 years with a median of 3 months. Thirty-nine (54.9%) children had karyotype testing done. The median age (IQR) of children with reported karyotypes and those without was 3.3 years (1.3-8.9) and 8.3 years (3.6-12.1), respectively (p=0.021). Based on karyotype analysis, 19 (48.7%) of karyotyped children had 46,XY DSD and 18 (46.2%) had 46,XX DSD. There were two (5.1%) children with sex chromosome DSD. Among the 71 patients, the most common presumed causes of DSD were ovotesticular DSD (14.1%) and CAH (11.3%). Majority (95.7%) of the patients presented with symptoms of DSD at birth. The most common presenting symptom was ambiguous genitalia, which was present in 66 (93.0%) patients either in isolation or in association with other symptoms. An ambiguous genitalia was initially observed by the patient's mother in 51.6% of 62 cases despite the high rate (84.7%) of delivery in hospital. Seventeen (23.9%) of the cases had a gender reassignment at final diagnosis. A psychologist/psychiatrist or counselor was involved in the management of 23.9% of the patients.

CONCLUSION

The commonest presumed cause of DSD was ovotesticular DSD in contrast to western studies, which found CAH to be more common. Investigation of DSD cases is expensive and needs to be supported. We would have liked to do molecular genetic analysis outside the country but financial challenges made it impossible. A network for detailed diagnostics in resource-limited countries would be highly desirable. There is a need to train health care workers and medical students for early diagnosis. Psychological evaluation should be carried out for all patients at diagnosis and support given for families.

Clinical Spectrum of Disorders of Sex Development: A Cross-sectional Observational Study

OBJECTIVE

Disorders of sex development (DSD) constitutes a small but difficult and equally important area of endocrinology. It is often a social emergency as the decision regarding sex assignment in these cases is extremely disturbing and difficult to both families and healthcare professionals. Our study was devised to assess the clinical and chromosomal profile of patients with suspected DSD and classify them according to the new DSD consensus document.

SUBJECTS AND METHODS

This study was a cross-sectional observational study carried out in the department of pediatrics of a tertiary care hospital from August 2012 to August 2014. All patients with suspected DSD in the age group of 0-19 years were included. After detailed history and examination, karyotyping, abdominal sonography, and hormonal analysis were done. Additional studies like gonadal biopsy, laparoscopy, and hormone stimulation tests were done in selected cases.

RESULTS

About 41 patients were included in the study. The mean age of presentation was 87 months (1 day to 16 years). Only seven (13.7%) patients presented in neonatal period. In total, 25 patients had ambiguous genitalia; 46, XX DSD were diagnosed in 24 (58.5%) patients, 46, XY DSD in 10 (24.4%) patients, and sex chromosome DSD in 7 (17.1%). Congenital adrenal hyperplasia (CAH) was the commonest disease diagnosed in 21 (51.2%) patients. Turner syndrome, Klinefelter syndrome, androgen insensitivity syndrome, 46, XX ovotesticular disorder, and 46, XY gonadal dysgenesis were diagnosed in 3, 3, 4, 3, and 5 patients, respectively. Eleven patients with CAH presented in shock and six had history of sib deaths.

CONCLUSION

46, XX DSD were the commonest etiological group in our study and CAH was the commonest individual disease. There is a need for educating general public and practitioners regarding DSD to allow early intervention. Moreover, there is a need to introduce routine neonatal screening for CAH in our country.

Gender Trouble in Social Psychology: How Can Butler's Work Inform Experimental Social Psychologists' Conceptualization of Gender?

A quarter of a century ago, philosopher Judith Butler (1990) called upon society to create "gender trouble" by disrupting the binary view of sex, gender, and sexuality. She argued that gender, rather than being an essential quality following from biological sex, or an inherent identity, is an act which grows out of, reinforces, and is reinforced by, societal norms and creates the illusion of binary sex. Despite the fact that Butler's philosophical approach to understanding gender has many resonances with a large body of gender research being conducted by social psychologists, little theorizing and research within experimental social psychology has drawn directly on Butler's ideas. In this paper, we will discuss how Butler's ideas can add to experimental social psychologists' understanding of gender. We describe the Butler's ideas from Gender Trouble and discuss the ways in which they fit with current conceptualizations of gender in experimental social psychology. We then propose a series of new research questions that arise from this integration of Butler's work and the social psychological literature. Finally, we suggest a number of concrete ways in which experimental social psychologists can incorporate notions of gender performativity and gender trouble into the ways in which they research gender.