Psychological research and intersex/DSD: recent developments and future directions

Psychological support for individuals with differences of sex development (DSD)

OBJECTIVE

Congenital conditions with atypical development of chromosomal, gonadal, or anatomic sex characteristics are referred to as Differences of Sex Development (DSD). Psychosocial care is recommended to be an integral part of clinical management for individuals with DSD. Few studies have examined the perceived need for, utilization of and the opinions of individuals with DSD regarding psychological support.

METHODS

This cross-sectional study was part of a European multicentre study in 14 different medical centres in six countries. In total, 1040 individuals with DSD participated in a patient-reported outcome questionnaire asking about experiences and opinions regarding psychological support in DSD care.

RESULTS

A majority of the participants reported that they had not received psychological support, in childhood and/or adolescence (70.6%, n = 692) nor in adulthood (67.9%, n = 661). Need for psychological support in childhood and/or adolescence was reported by 51.3% (n = 503), need for psychological support in adulthood, was reported by 49.5% (n = 482). The majority (80.2%; n = 718) agreed with the statement that people with DSD should always be offered psychological support. According to 78.7% (n = 697) of the participants, parents of children with DSD should always be offered psychological support.

CONCLUSION

Our findings support the existing consensus that psychological support should be an integral part of DSD care. The discrepancy between received and perceived need for psychological support suggests that individuals with DSD experience barriers to access mental health care services. Psychosocial and psychological services for children, adolescents and adults should therefore be available and offered throughout the lifespan to individuals with DSD.

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

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

Inside the doctor's office. Talking about intersex with Italian health professionals

This article explores how health professionals in Italy understand variations of sex characteristics (VSC), also referred to as intersex and/or disorders of sex development (DSD). With estimates of VSC frequency ranging from 0.018% to 1.7%, only a handful of highly specialised medical doctors are considered DSD experts. When addressing the daily health management of children and families who do not live near specialist DSD centres, these experts may refer individuals to the nearest health professional that Italian health services provides, opening up questions regarding how these professionals might act and react when faced with VSC. In this analysis of interview data from 65 Italian general practitioners, paediatricians and psychologists, we address two themes. The first theme discusses participants' previous experiences and case management, with a focus on social, medical and gender biases. The second theme examines health professionals' opinions and perspectives on ongoing conflicts concerning current best care practices. Our results highlight health professionals' cultural and gendered biases, confirming the need to develop specific professional training, guidelines and policies to improve the healthcare of people with VSC.

Moving intersex/DSD rights and care forward: Lay understandings of common dilemmas

When sex characteristics develop in ways that do not conform to binary models, dilemmas arise regarding how to understand the situation and what terminology to use to describe it. While current medical nomenclature suggests that it should be understood as a disorder of sex development (DSD) prompting medical responses, many describe intersex as a human variation in sexed embodiment that should be protected under discrimination laws. These opposing perspectives suggest different principles to employ in responding to dilemmas about gender assignment, early genital surgery and full disclosure of medical information. In this discursive psychological study, we explore how lay people, without prior knowledge or experience of intersex/DSD, make sense of these dilemmas and the underpinning discourses giving rise to how they talk about these situations. By using the discursive framework of ideological dilemmas, we analyse how people make sense of sex and gender (as binary or non-binary), how they deal with difference (as problematic or not), and how they understand who is in a position to make decisions in such situations. We conclude that engaging with dilemmas in-depth is more constructive than favouring one principle over others in moving social science research, reflexive clinical practice, and wider political debates on intersex/DSD forward.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Development of Health-Related Quality of Life Instruments for Young Children With Disorders of Sex Development (DSD) and Their Parents

Objective

Research in disorders of sex development (DSD) is hindered by a lack of standardized measures sensitive to the experiences of affected children and families. We developed and evaluated parent proxy (children 2-6 years) and parent self-report (children ≤6 years) health-related quality of life (HRQoL) instruments for DSD.

Methods

Items were derived from focus groups and open-ended interviews. Clarity and comprehensiveness were assessed with cognitive interviews. Psychometric properties were examined in a field survey of 94 families.

Results

Measures demonstrated adequate to good psychometrics, including internal consistency, test-retest reliability, convergent validity, and ability to detect known-group differences. Parents reported greatest stress on Early Experiences , Surgery , and Future Concerns scales.

Conclusions

These instruments identify patients' and families' needs, monitor health and quality of life status, and can evaluate clinical interventions. Findings highlight the need for improved psychosocial support during the diagnostic period, better parent-provider communication, and shared decision-making. HRQoL measures are needed for older youth.

Health-related quality of life and psychological well-being in adults with differences/disorders of sex development

OBJECTIVE

Rare congenital conditions with incongruence of chromosomal, gonadal and phenotypic sex have been classified as differences/disorders of sex development (DSD). Included in DSD are conditions with diverse genetic aetiology, varying levels of prenatal androgen effects, phenotypes and, subsequently, different medical treatments. Quality of life (QoL) and psychological well-being are indicators of successful psychosocial adaptation to the conditions. We sought to investigate the HRQoL and psychological well-being in this population.

DESIGN

This multicentre clinical evaluation study was part of a German network related to DSD funded by the German Ministry of Science and Education (BMBF 2003 to 2007).

METHODS

To assess health-related quality of life (HRQoL), we used the Short Form Health Survey (SF-36), and for psychological well-being, the Brief Symptom Inventory (BSI). Participants were classified into five groups: females with CAH, females with XY DSD conditions where there is a partial androgen effect (partial androgen insensitivity, mixed/partial gonadal dysgenesis, disorders of androgen biosynthesis), females with XY DSD without androgen effect (complete androgen insensitivity, complete gonadal dysgenesis), males with XY DSD, and individuals with DSD conditions and other gender.

RESULTS

Participants included 110 adults with DSD (age range 17-62). We found a trend of lowered mental HRQoL and significant higher physical HRQoL for participants as compared to the norm. The high physical HRQoL especially applied to females with androgen effect and XY karyotype. Participants reported significant higher psychological distress compared to the norm. Forty-seven participants (42·7%) reported distress in a clinically relevant range on the BSI.

CONCLUSIONS

Although we did not find significant impairments in overall HRQoL, participants reported significant impaired psychological well-being. Specialized interdisciplinary care should focus in particular on psychological issues to ensure good overall health and well-being.

Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care

The goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups. The goal of patient care is focused upon the best possible quality of life (QoL). The field of DSD is continuously developing. An update on the clinical evaluation of infants and older individuals with ambiguous genitalia including perceptions regarding male or female assignment is discussed. Topics include biochemical and genetic assessment, the risk of germ cell tumor development, approaches to psychosocial and psychosexual well-being and an update on support groups. Open and on-going communication with patients and parents must involve full disclosure, with the recognition that, while DSD conditions are life-long, enhancement of the best possible outcome improves QoL. The evolution of diagnosis and care continues, while it is still impossible to predict gender development in an individual case with certainty. Such decisions and decisions regarding surgery during infancy that alters external genital anatomy or removes germ cells continue to carry risk.

Follow-up of psychological outcomes of interventions in patients diagnosed with disorders of sexual development: A systematic review

The objective of this study was to perform a systematic review of articles that followed up the psychological outcomes of interventions in patients with disorders of sexual development. The analysis focused on the methodological quality of the studies and the assumptions on the evaluation of the intervention outcomes. The review signaled the need for better consideration about the complexity of intersexuality and for a shift from the anatomical/functional/aesthetic to the subjective outcomes related to patient’s quality of life. Furthermore, it is suggested that the interventions should be better investigated, given the lack of evidence for the necessity of early procedures.

The experience of women living with Congenital Adrenal Hyperplasia: impact of the condition and the care given

CONTEXT

Congenital adrenal hyperplasia (CAH) is caused most often by mutations in the CYP21A2 gene, resulting in cortisol and aldosterone deficiency and increased production of androgens.

OBJECTIVE

To describe how women with CAH experience their condition and the care given.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews with 13 adult Swedish women with CAH were transcribed. Data were analysed by qualitative content analysis to describe the variability in the experiences.

MAIN OUTCOME MEASURES

Qualitative evaluation of the participants' life experiences.

RESULTS

The participants' experiences of having CAH are described in four different categories. 1. Information comprises the experiences of interaction with healthcare providers, knowledge acquisition and information disclosure. 2. Exposure encompasses the experiences of genital examinations, the medical focus on the genitalia and of being photographed repeatedly. 3. Health covers the self-perceived experiences of having a medical condition that requires pharmacological treatment and sometimes surgery. 4. Research comprises the experiences of having a scientifically well-studied condition. Different experiences of shame reoccur in all categories, thus forming the latent theme.

CONCLUSION

The experience of living with congenital adrenal hyperplasia can be facilitated by increased information and by acknowledging that women with CAH are a heterogeneous group with individual needs. Shame may be counterbalanced by increased parental support and increased knowledge among healthcare personnel aimed at providing children with continuous support and coping strategies during their upbringing. Based on the identified themes in this study, there are several research avenues to pursue in the future.