Psychological aspects of intersex in Saudi patients

A clínica da intersexualidade e seus desafios para os profissionais de saúde

A partir de uma revisão crítica da literatura sobre a intersexualidade, discutem-se as abordagens clínicas adotadas em casos de ambigüidade da genitália externa e/ou interna, diagnosticados como pseudo-hermafroditismo masculino, pseudo-hermafroditismo feminino e hermafroditismo verdadeiro. Tendo em vista a necessidade de fundamentação nas questões concernentes ao desenvolvimento psicológico, em especial a aquisição da identidade de gênero e o desempenho do papel de gênero, são enfatizadas as dificuldades envolvidas na tomada de decisão terapêutica e acompanhamento pelos profissionais que integram a equipe de saúde. Visando fornecer sugestões para futuros trabalhos nos planos científico e assistencial é traçado um panorama das recentes pesquisas.

Ambiguous genitalia, gender-identity problems, and sex reassignment

This article discusses general issues with regard to gender-identity problems, sex reassignment, and clinical management in patients with ambiguous genitalia, based on a detailed case history of a patient with penile agenesis who has been followed more than 20 years. After initial uncertainty, the patient began to grow up as a boy, lived from the fourth year of life as a girl and young woman, and lived from late puberty on as a man. Over his lifetime he experienced extensive corrective surgery plus hormonal substitution therapy. Pre- and perinatal hormonal conditions, phenomenology of the genitalia, sex of rearing, timing of sex reassignment and corrective surgery, for example, appear to be important components for the development of gender-role behavior, gender identity, and sexual orientation of intersex patients. Findings and retrospective considerations for this patient suggest the need for careful differential activities in diagnostic workup, approaches to sex assignment and possible reassignment, and the clinical management of patients and families.

Gender identity and role in a pedigree of Arabs with intersex due to 5 alpha reductase-2 deficiency

Between 1986 and 1995, a pedigree of six Arabs with male pseudohermaphroditism due to 5 alpha reductase-2 deficiency have been identified. All, were raised as girls since birth. At the time of diagnosis, three were post-pubertal, one pubertal and two pre-pubertal. The external genitalia of 'pseudo-vaginal perineoscrotal hypospadias' was identical in these subjects. Although these individuals were a homogeneous group in terms of their sex of upbringing, phenotypic appearance, endocrinological profile and socio-cultural background, the development of the gender identity and role was not uniform in these six cases. Their psycho-sexual make-up was closely related to the transaction of their life experiences. These cases provide further insight into the interaction between various factors involved in the development of gender identity and role in male pseudohermaphrodites in an Eastern culture.

Sex reassignment: A challenging problem - current medical and islamic guidelines

Sexual ambiguity is a complex and often confusing medical problem. In addition to the life-threatening adrenal crises which may accompany some forms, ambiguity of the genitalia may lead to incorrect sex assignment by parents and/or health personnel. Children who present to medical attention beyond the neonatal period constitute a challenging problem due to the grave consequences of this condition. Thirty cases in whom sex reassignment was indicated were seen at King Khalid University Hospital, Riyadh, over a 10-year period. Of these, 27 (90%) were genetic females (20 were 21- and seven were 11-hydroxylase deficient) and three (10%) were genetic males (two partial androgen insensitive and one 5alpha-reductase deficient). All genetic males who were incorrectly assigned as females accepted reassignment. But 9 out of 27 (33%) of the genetic females who were incorrectly assigned as males refused reassignment. Preference for male sex assignment, delayed diagnosis and sociocultural circumstances seem to be the contributing factors for refusal. A national consensus about this important issue strengthened by the existing religious recommendations in demanded.

Male pseudohermaphroditism: factors determining the gender of rearing in Saudi Arabia

OBJECTIVE

Experience with male pseudohermaphrodites at King Fahd Hospital of King Faisal University, Al-Khobar, Saudi Arabia from 1981 to 1991 was reviewed to ascertain the factors determining the gender of rearing.

METHODS

The records of 14 patients consisting of 6 prepubertal and 8 postpubertal patients were studied. None of the patients had any prior evaluation or treatment, since their gender assignment at birth was carried out by midwives in rural communities. The males presented to our hospital with ambiguous genitalia: small phallus, bifid scrotum, perineoscrotal hypospadias, and undescended testes (UDT). Most of those raised as females presented in the postpubertal period seeking remedy for deep voice, excessive musculature, facial hair, erection of the phallus, ejaculation, inappropriate attraction to the female sex, and primary amenorrhea. As their male genotype became determined, all the patients and/or their parents, with the exception of one, insisted on appropriate reconstructive surgery to the male gender. This report focuses primarily on 11 patients assigned a female gender at birth, 10 of whom insisted on a gender change.

RESULTS

Most adolescents and adults still complained of small penises after reconstructive surgery, but cherished their male role.

CONCLUSIONS

The male genotype is a more important factor than phallic adequacy in determining the gender of rearing in the Kingdom of Saudi Arabia, an observation attributable to the financial, social, and cultural benefits that the male gender confers in Saudi society.

Intersexuality and the diagnosis of gender identity disorder

Problems of gender identity development are the core concern in the psychosocial management of medical conditions involving ambiguous genitalia. This report discusses the difficulties encountered in applying the DSM category and criteria of Gender Identity Disorder (GID) to such patients. Data on prevalence, age of onset or presentation, sex ratio, and associated or predictive factors also suggest marked differences between intersex patients with gender identity problems and nonintersex patients with GID. Patients with intersexuality or similar medical conditions should be excluded from the GID diagnosis.