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Traino KA, Ciciolla LM, Perez MN, Chaney JM, Welch G, Baskin LS, Buchanan CL, Chan YM, Cheng EY, Coplen DE, Wisniewski AB, Mullins LL. Trajectories of illness uncertainty among parents of children with atypical genital appearance due to differences of sex development. J Pediatr Psychol 2024:jsae043. [PMID: 38857449 DOI: 10.1093/jpepsy/jsae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 04/14/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE The present study aimed to identify distinct trajectories of parental illness uncertainty among parents of children born with atypical genital appearance due to a difference of sex development over the first year following diagnosis. It was hypothesized that four trajectory classes would emerge, including "low stable," "high stable," "decreasing," and "increasing" classes, and that select demographic, familial, and medical factors would predict these classes. METHODS Participants included 56 mothers and 43 fathers of 57 children born with moderate to severe genital atypia. Participants were recruited from eleven specialty clinics across the U.S. Growth mixture modeling (GMM) approaches, controlling for parent dyad clustering, were conducted to examine classes of parental illness uncertainty ratings over time. RESULTS A three-class GMM was identified as the best-fitting model. The three classes were interpreted as "moderate stable" (56.8%), "low stable" (33.0%), and "declining" (10.3%). Findings suggest possible diagnostic differences across trajectories. CONCLUSIONS Findings highlight the nature of parents' perceptions of ambiguity and uncertainty about their child's diagnosis and treatment the year following their child's birth/diagnosis. Future research is needed to better understand how these trajectories might shift over the course of the child's development. Results support the development of tailored, evidence-based interventions to address coping with uncertainty among families raising a child with chronic health needs.
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Affiliation(s)
- Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Lucia M Ciciolla
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Megan N Perez
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - John M Chaney
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Ginger Welch
- Department of Human Development and Family Sciences, Oklahoma State University, Stillwater, OK, United States
| | - Laurence S Baskin
- Department of Urology, University of California San Francisco Medical Center, San Francisco, CA, United States
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Yee-Ming Chan
- Division of Endocrinology, and Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Douglas E Coplen
- Division of Urologic Surgery, St. Louis Children's Hospital, St Louis, MO, United States
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
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Carpenter M, Kraus C, Earp BD. "Should we correct hypospadias during childhood?" A question of facts and values. J Pediatr Urol 2024; 20:432-433. [PMID: 38355383 DOI: 10.1016/j.jpurol.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Morgan Carpenter
- School of Public Health, Sydney Health Ethics, The University of Sydney, Australia
| | - Cynthia Kraus
- Faculty of Social and Political Sciences, University of Lausanne, Switzerland
| | - Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
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Avanceña AL, Rose AM, Gardner MD, Rutter MM, Schafer-Kalkhoff T, Suorsa-Johnson KI, van Leeuwen KD, Weidler EM, Gebremariam A, Sandberg DE, Prosser LA. Preferences in Clinical Care of Individuals With Differences of Sex Development. Pediatrics 2024; 153:e2023064207. [PMID: 38699802 PMCID: PMC11153319 DOI: 10.1542/peds.2023-064207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVES To identify the most important attributes related to the process of achieving, and outcomes associated with, successful care for differences of sex development (DSD). METHODS We developed a best-worst scaling survey administered to 520 DSD stakeholders, including individuals or family members of those with DSD, health care specialists, and patient support and advocacy representatives. Fourteen process-related attributes and 16 outcome-related attributes were identified through qualitative research. We estimated relative importance scores and coefficients from regression analysis to understand the relative importance of attributes and conducted latent class analysis to explore heterogeneity in preferences. RESULTS The 3 most important process attributes were (1) good communication between care team and patient/family, (2) care team educated patient/family about condition, and (3) care team incorporates the values of patient/family. The 3 most important outcome attributes were (1) patient satisfaction, (2) patient mental health, and (3) treatment maintains physical health. Latent class analyses showed that respondents had heterogeneous preferences. For process-related attributes, we identified 3 respondent groups: "Patient autonomy and support" (46% of respondents), "Education and care transitions" (18%), and "Shared decision-making" (36%). For outcome-related attributes, we identified 2 respondent groups: "Preserving function and appearance" (59% of respondents) and "Patient health and satisfaction" (41%). CONCLUSIONS Outcomes such as patient satisfaction and health were the most important outcome attributes, and good communication and education from the care team were the most important process attributes. Respondents expressed heterogeneous preferences for selected DSD care attributes that providers should consider to improve satisfaction with and quality of DSD care.
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Affiliation(s)
- Anton L.V. Avanceña
- Health Outcomes Division, College of Pharmacy
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Texas
| | - Angela M. Rose
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Melissa D. Gardner
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Meilan M. Rutter
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kristina I. Suorsa-Johnson
- Division of Pediatric Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona
- Accord Alliance, Higley, Arizona
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Michigan Medicine
- Department of Pediatrics, Michigan Medicine
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Matsubara K, Ohgami Y, Okamura K, Aoto S, Fukami M, Shimada Y. Machine learning trial to detect sex differences in simple sticker arts of 1606 preschool children. Minerva Pediatr (Torino) 2024; 76:343-349. [PMID: 38842380 DOI: 10.23736/s2724-5276.21.06067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Previous studies suggested that drawings made by preschool boys and girls show distinguishable differences. However, children's drawings on their own are too complexly determined and inherently ambiguous to be a reliable indicator. In the present study, we attempted to develop a machine learning algorithm for classification of sex of the subjects using children's artworks. METHODS We studied three types of simple sticker artworks from 1606 Japanese preschool children aged 51-83 months (803 boys and 803 girls). Those artworks were processed into digitalized data. Simulated data based on the original data were also generated. Logistic regression approach was applied to each dataset to make a classifier, and run on each dataset in a stratified ten-fold cross-validation with hyperparameter tuning. A probability score was calculated in each sample and utilized for sex classification. Prediction performance was evaluated using accuracy, recall, and precision scores, as well as learning curves. RESULTS Two models created from the original and simulated data showed comparably low metrics. The distributions of probability scores in the samples from boys and girls mostly overlapped and were indistinguishable. Learning curves of the models showed an extremely under-fitted pattern. CONCLUSIONS Our machine learning algorithm was unable to distinguish simple sticker arts created by boys and girls. More complex tasks will enable to develop an accurate classifier.
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Affiliation(s)
- Keiko Matsubara
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yuko Ohgami
- Department of Child Development and Education, Faculty of Humanities, Wayo Women's University, Chiba, Japan
| | - Koji Okamura
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, Setagaya, Tokyo, Japan
| | - Saki Aoto
- Medical Genome Center, National Research Institute for Child Health and Development, Setagaya, Tokyo, Japan
| | - Maki Fukami
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan -
| | - Yukiko Shimada
- Department of Child Studies, Faculty of Human Development, Kokugakuin University, Kanagawa, Japan
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5
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Santos HC, Barros BA, El-Beck MS, Miranda ML, Guaragna MS, Fabbri-Scallet H, Mazzola TN, Vieira TP, Mello MP, Marques-de-Faria AP, Maciel-Guerra AT, Guerra-Junior G. Patients with genital ambiguity referred without a sex definition: the relationship between clinical picture and defined sex of rearing. J Pediatr (Rio J) 2024:S0021-7557(24)00069-X. [PMID: 38823786 DOI: 10.1016/j.jped.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE It was to verify the association between the definition of sex of rearing and, clinical and cytogenetic features among patients with genital ambiguity referred without a sex assignment. METHODS The sample consisted of 133 patients with genital ambiguity seen at a single reference service. These patients did not have a defined social sex at the first consultation and their etiological diagnosis was obtained during follow-up. RESULTS A total of 133 cases were included, 74 of which were reared as males and 59 as females. No correlation was found between the year of birth and the year of the first consultation with the definition of sex of rearing. However, the definition of sex of rearing was associated with age at the first consultation, severity of genital ambiguity, presence of palpable gonad(s), presence of uterus on ultrasound, karyotype, and diagnosis. Palpable gonad(s), more virilized genitalia, absence of a uterus on ultrasound, 46, XY karyotype, or a karyotype with sex chromosome abnormalities emerged as strong predictors for defining male sex. All 77 (58 %) patients over 18 years old had a gender identity in accordance with the sex of rearing; though 9 of 77 (12 %) had homo or bisexual orientation, especially girls with Congenital Adrenal Hyperplasia. CONCLUSIONS Clinical and cytogenetic data were strongly associated with the definition of the sex of rearing of children with genital ambiguity referred to a DSD center without sex assignment. Management in a specialized center allows the establishment of a gender identity in accordance with the sex of rearing.
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Affiliation(s)
- Henrique C Santos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Beatriz A Barros
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Mayra S El-Beck
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Marcio L Miranda
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Mara S Guaragna
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Helena Fabbri-Scallet
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Taís N Mazzola
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Tarsis P Vieira
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Maricilda P Mello
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Antonia P Marques-de-Faria
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Andrea T Maciel-Guerra
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Gil Guerra-Junior
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil.
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Eitel KB, Hodax JK. Evaluation and medical care of intersex and gender diverse youth. Pediatr Radiol 2024:10.1007/s00247-024-05948-y. [PMID: 38782777 DOI: 10.1007/s00247-024-05948-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
While there is considerable overlap in the treatment of patients with intersex traits and differences in sex development (I/DSD) with transgender and gender diverse (TGD) youth, the initial medical evaluation varies significantly. I/DSD youth often present due to differences in genitalia development in infancy or pubertal development in adolescence, and this leads to comprehensive biochemical, radiologic, and genetic evaluation. TGD youth, however, tend to have typical development noted at birth and during puberty, but present with a gender identity that does not align with their sex assigned at birth and do not require evaluation for underlying pathology. For both I/DSD and TGD youth, the mainstays of treatment are to better align one's physical appearance to their gender identity. This review discusses the non-medical and medical interventions utilized in gender affirming care. A multidisciplinary team of mental health providers, pediatric medical providers, and surgeons is recommended for providing gender affirming care to both I/DSD youth and TGD youth and their families. Radiologists have an important role in initial evaluation of I/DSD youth and in ongoing monitoring of growth and bone mineral density during puberty induction in I/DSD and TGD youth.
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Affiliation(s)
- Kelsey B Eitel
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA
| | - Juanita K Hodax
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA.
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Stancampiano MR, Meroni SLC, Bucolo C, Russo G. 46,XX Differences of Sex Development outside congenital adrenal hyperplasia: pathogenesis, clinical aspects, puberty, sex hormone replacement therapy and fertility outcomes. Front Endocrinol (Lausanne) 2024; 15:1402579. [PMID: 38841305 PMCID: PMC11150773 DOI: 10.3389/fendo.2024.1402579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024] Open
Abstract
The term 'differences of sex development' (DSD) refers to a group of congenital conditions that are associated with atypical development of chromosomal, gonadal, and/or anatomical sex. DSD in individuals with a 46,XX karyotype can occur due to fetal or postnatal exposure to elevated amount of androgens or maldevelopment of internal genitalia. Clinical phenotype could be quite variable and for this reason these conditions could be diagnosed at birth, in newborns with atypical genitalia, but also even later in life, due to progressive virilization during adolescence, or pubertal delay. Understand the physiological development and the molecular bases of gonadal and adrenal structures is crucial to determine the diagnosis and best management and treatment for these patients. The most common cause of DSD in 46,XX newborns is congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, determining primary adrenal insufficiency and androgen excess. In this review we will focus on the other rare causes of 46,XX DSD, outside CAH, summarizing the most relevant data on genetic, clinical aspects, puberty and fertility outcomes of these rare diseases.
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López Soto Á, Velasco Martínez M, Ferrández Martínez M, Díaz García A, García Izquierdo O, Marín Sánchez P. Prenatal ambiguous/atypical genitalia: why are we still missing it and how can we improve diagnosis? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:581-585. [PMID: 37773980 DOI: 10.1002/uog.27507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Á López Soto
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - M Velasco Martínez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - M Ferrández Martínez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - A Díaz García
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - O García Izquierdo
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - P Marín Sánchez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
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9
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Jiang W, Yu J, Mao Y, Tang Y, Cao L, Du Q, Li J, Yang J. Identification and functional analysis of a rare variant of gene DHX37 in a patient with 46,XY disorders of sex development. Mol Genet Genomic Med 2024; 12:e2453. [PMID: 38769888 PMCID: PMC11106588 DOI: 10.1002/mgg3.2453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/20/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND 46,XY sex reversal 11 (SRXY11) [OMIM#273250] is characterized by genital ambiguity that may range from mild male genital defects to gonadal sex reversal in severe cases. DHX37 is an RNA helicase that has recently been reported as a cause of SRXY11. So far, a total of 21 variants in DHX37 have been reported in 58 cases with 46,XY disorders of sex development (DSD). METHODS Whole exome sequencing (WES) was conducted to screen for variations in patients with 46,XY DSD. The subcellular localization of mutant DHX37 proteins was detected by immunofluorescence. And the levels of mutant DHX37 proteins were detected via Western blotting. RESULTS A novel pathogenic variant of DHX37 was identified in a patient with 46,XY DSD c.2012G > C (p.Arg671Thr). Bioinformatics analysis showed that the protein function of the variant was impaired. Compared with the structure of the wild-type DHX37 protein, the number of hydrogen bonds and interacting amino acids of the variant protein were changed to varying degrees. In vitro assays revealed that the variant had no significant effect on the intracellular localization of the protein but significantly reduced the expression level of the protein. CONCLUSIONS Our finding further expands the spectrum of the DHX37 variant and could assist in the molecular diagnosis of 46,XY DSD patients.
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Affiliation(s)
- Wei Jiang
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Centre for Medical Genetics, Sichuan Academy of Medical Sciences, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical SciencesChengduChina
| | - Jing Yu
- Meishan Women and Children's HospitalAlliance Hospital of West China Second University Hospital, Sichuan UniversityMeishanChina
| | - Yu Mao
- Department of Pediatric Surgery, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Yunman Tang
- Department of Pediatric Surgery, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Li Cao
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Centre for Medical Genetics, Sichuan Academy of Medical Sciences, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical SciencesChengduChina
| | - Qin Du
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Centre for Medical Genetics, Sichuan Academy of Medical Sciences, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical SciencesChengduChina
| | - Jianan Li
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Centre for Medical Genetics, Sichuan Academy of Medical Sciences, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical SciencesChengduChina
| | - Jiyun Yang
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Centre for Medical Genetics, Sichuan Academy of Medical Sciences, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Research Unit for Blindness Prevention of Chinese Academy of Medical Sciences (2019RU026), Sichuan Academy of Medical SciencesChengduChina
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El Haddar Z, El ouali A, Ghanam A, Benajiba N, Rkain M, Babakhouya A. A rare case of steroid 11 beta-hydroxylase deficiency in a child revealed by acute pulmonary edema. Oxf Med Case Reports 2024; 2024:omae042. [PMID: 38784773 PMCID: PMC11110861 DOI: 10.1093/omcr/omae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/12/2024] [Accepted: 03/26/2024] [Indexed: 05/25/2024] Open
Abstract
We report the case of a 5-year-old boy diagnosed with congenital adrenal hyperplasia due to 11-hydroxylase deficiency, revealed by disorders of sex development (DSD) and acute pulmonary edema due to severe hypertension. We considered the diagnosis based on biological and radiological examinations. The sociocultural background and the delayed diagnosis had a significant impact on the therapeutic decisions. All babies should be screened for 11 beta-hydroxylase deficiency, there should be specialized and interdisciplinary medical centers, and early detection is essential to avoiding serious complications of this disease.
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Affiliation(s)
- Zohair El Haddar
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Aziza El ouali
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Ayad Ghanam
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Noufissa Benajiba
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Maria Rkain
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
| | - Abdeladim Babakhouya
- Department of Pediatrics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
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11
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Jamal L, Zayhowski K, Berro T, Baker K. Queering genomics: How cisnormativity undermines genomic science. HGG ADVANCES 2024; 5:100297. [PMID: 38637989 PMCID: PMC11129102 DOI: 10.1016/j.xhgg.2024.100297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024] Open
Abstract
Over the past century, genetics and genomics ("genomics") have contributed significantly to our knowledge of human biology and disease. Genomics has also bolstered inaccurate and harmful arguments about "essential" differences between socially defined groups. These purported differences have reinforced class hierarchies and justified the mistreatment of groups such as Black people, Indigenous people, and other people of color and/or people with disabilities. With this history in mind, we explore how genomics is used to reinforce scientifically unsound understandings of the relationship between two fundamental aspects of the human experience: sex and gender. We argue that imprecise, inaccurate practices for collecting data and conducting genomic research have adversely influenced genomic science and can contribute to the stigmatization of people whose sex and/or gender challenge binary expectations. The results have been to preclude transgender and intersex people from accessing high-quality, evidence-based healthcare and to hinder their participation in scientifically sound research. In this perspective, we use the lens of queer theory to render this situation more visible. First, we highlight the theoretical contributions queer theory can make to genomic science. Second, we examine practices in research and clinical genomics that exclude and stigmatize transgender and intersex people. Third, we highlight the ways that many current genomic research practices generate false conclusions that are used to support unjust public policies. We conclude by recommending ways that clinicians and researchers can-and should-harness the scientific, social, and cultural power of genomics to advance knowledge and improve lives across the spectra of sex and gender.
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Affiliation(s)
- Leila Jamal
- Genetics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA; Bioethics Department, National Institutes of Health, Bethesda, MD, USA.
| | - Kimberly Zayhowski
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Tala Berro
- Department of Genetics, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Kellan Baker
- Whitman-Walker Institute, Washington, DC, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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12
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Menashe SJ, Zavaletta V, McCoy MN, Wright JN. Advocacy in gender affirming care. Pediatr Radiol 2024:10.1007/s00247-024-05885-w. [PMID: 38436706 DOI: 10.1007/s00247-024-05885-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
Healthcare advocacy is the duty and privilege of all healthcare providers, but especially for those who care for children. Intersex and gender diverse youth face significant barriers across many aspects of life, with access to competent gender affirming healthcare chief among them. Understanding the importance of both institutional and individual efforts in healthcare advocacy is paramount to improving healthcare access and outcomes for this population.
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Affiliation(s)
- Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, University of Washington, MA.7.220, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | - Vaz Zavaletta
- Department of Pediatric Radiology, Children's Hospital Chicago, University of Colorado Hospital, Aurora, CO, USA
| | | | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, University of Washington, MA.7.220, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
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13
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Crocetti D, Berry A, Monro S. Navigating the complexities of adult healthcare for individuals with variations of sex characteristics: from paediatric emergencies to a sense of abandonment. CULTURE, HEALTH & SEXUALITY 2024; 26:332-345. [PMID: 37199261 DOI: 10.1080/13691058.2023.2208194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
Intersex people and those with variations of sex characteristics face significant health and social issues. This paper analyses the complexities of adult healthcare for this diverse population, including the root causes of deficiencies in care provision. Many minors with variations of sex characteristics are subjected to irreversible, non-consensual medical interventions, which can have negative effects on their health and wellbeing as adults. This 'emergency' approach to intersex paediatric healthcare has been challenged since the 1990s, but there is still a lack of understanding about how the paradigm affects adult care. This paper aims to raise awareness of the health challenges faced by adults with variations of sex characteristics. It identifies themes related to the challenges associated with accessing appropriate adult care, including the repercussions of childhood treatment, the lack of transitional services and psychological support, the limited general medical knowledge about variations of sex characteristics, and the reluctance to access services due to fear of stigma or past medical trauma. The paper indicates the need for more attention to intersex people's health needs as adults, moving away from attempts to 'fix' them as minors towards approaches which consider and provide for their diverse healthcare needs in a broader temporal context.
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Affiliation(s)
- Daniela Crocetti
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
- subsequently Independent Researcher, Intersexesiste NGO, Bologna, Italy
| | - Adeline Berry
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Surya Monro
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
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14
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Wang Y, Xu Y, Zhang H, Yin D, Pan Y, He X, Li S, Cheng Z, Zhu G, Zhao T, Huang H, Zhu M. Four novel mutations identification in 17 beta-hydroxysteroid dehydrogenase-3 deficiency and our clinical experience: possible benefits of early treatment. Front Endocrinol (Lausanne) 2024; 14:1267967. [PMID: 38425490 PMCID: PMC10902039 DOI: 10.3389/fendo.2023.1267967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction Individuals with 17-beta-hydroxysteroid dehydrogenase type 3 (17β-HSD3) deficiency face a multitude of challenges, primarily concerning genital appearance, potential malignancy risks, and fertility issues. This study reports our findings from an investigation involving five individuals affected by 17β-HSD3 deficiency, ranging in age from pre-adolescence to adolescence. Notably, we identified four previously unreported mutations in these subjects. Methods Our study included a comprehensive evaluation to determine the potential occurrence of testicular tumors. The methods involved clinical examinations, genetic testing, hormone profiling, and patient history assessments. We closely monitored the progress of the study subjects throughout their treatment. Results The results of this evaluation conclusively ruled out the presence of testicular tumors among our study subjects. Moreover, four of these individuals successfully underwent gender transition. Furthermore, we observed significant improvements in genital appearance following testosterone treatment, particularly among patients in the younger age groups who received appropriate treatment interventions. Discussion These findings underscore the critical importance of early intervention in addressing concerns related to genital appearance, based on our extensive clinical experience and assessments. In summary, our study provides insights into the clinical aspects of 17β-HSD3 deficiency, emphasizing the vital significance of early intervention in addressing genital appearance concerns. This recommendation is supported by our comprehensive clinical assessments and experience.
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Affiliation(s)
- Yunpeng Wang
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
- Office of Academic Research, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Laboratory of Developmental Biology, Department of Cell Biology and Genetics, School of Basic Medical Sciences, Chongqing Medical University, Chongqing, China
| | - Yu Xu
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing College of Humanities, Science and Technology, Chongqing, China
| | - Huijiao Zhang
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Danyang Yin
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yiming Pan
- Laboratory of Developmental Biology, Department of Cell Biology and Genetics, School of Basic Medical Sciences, Chongqing Medical University, Chongqing, China
| | - Xiwen He
- Laboratory of Developmental Biology, Department of Cell Biology and Genetics, School of Basic Medical Sciences, Chongqing Medical University, Chongqing, China
- School of Life Sciences and Technology, ShanghaiTech University, Shanghai, China
| | - Shuaiting Li
- Office of Academic Research, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi Cheng
- Laboratory of Developmental Biology, Department of Cell Biology and Genetics, School of Basic Medical Sciences, Chongqing Medical University, Chongqing, China
| | - Gaohui Zhu
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ting Zhao
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huizhe Huang
- Office of Academic Research, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Zhu
- Department of Endocrine and Metabolic Diseases Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
- Office of Academic Research, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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15
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Gramc M. Challenges in Transition of Care for People with Variations in Sex Characteristics in the European Context. Healthcare (Basel) 2024; 12:354. [PMID: 38338239 PMCID: PMC10855080 DOI: 10.3390/healthcare12030354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE People with variations in sex characteristics (VSCs) have been receiving inadequate care for many decades. The Chicago consensus statement in 2006 aimed to introduce improved comprehensive care, which would include the transition of care from pediatric to adult services organized by multidisciplinary teams. Yet, the evidence for transitional care is scarce. The aim of this paper is to outline the delivery of transition of care for adolescents and young adults with VSCs. METHOD Seven focus groups were conducted with health care professionals and peer support groups by care teams in Central, Northern, and Western Europe. The data from the focus groups were examined using reflexive thematic analysis. RESULTS Even though the transition of care has been implemented in the last two decades, it remains inadequate. There are differences among countries, as the quality of care depends on available resources and variations in sex characteristics. Moreover, there are significant hurdles to adequate transition of care, as there is lack of time and funding. The lack of adult care providers and psychosocial support often leaves young adults with VSCs to navigate the health care system alone. CONCLUSION The outcome of the study shows that the transition of care is organized through the department of pediatric endocrinology. The quality of care varies due to resources and variations in sex characteristics. A lack of adult specialists, and especially psychosocial support, represents the biggest obstacle for young adults and adults in navigating the health care system and for improvements in the provision of health care to adults. There is a risk of re-traumatization, as adolescents and young adults must often repeat their medical history and educate adult care providers who are insufficiently trained and knowledgeable.
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Affiliation(s)
- Martin Gramc
- Institute of Biomedical Ethics and the History of Medicine, University of Zürich, 8006 Zürich, Switzerland
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16
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Anastasiadou K, Silva M, Booth T, Speidel L, Audsley T, Barrington C, Buckberry J, Fernandes D, Ford B, Gibson M, Gilardet A, Glocke I, Keefe K, Kelly M, Masters M, McCabe J, McIntyre L, Ponce P, Rowland S, Ruiz Ventura J, Swali P, Tait F, Walker D, Webb H, Williams M, Witkin A, Holst M, Loe L, Armit I, Schulting R, Skoglund P. Detection of chromosomal aneuploidy in ancient genomes. Commun Biol 2024; 7:14. [PMID: 38212558 PMCID: PMC10784527 DOI: 10.1038/s42003-023-05642-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024] Open
Abstract
Ancient DNA is a valuable tool for investigating genetic and evolutionary history that can also provide detailed profiles of the lives of ancient individuals. In this study, we develop a generalised computational approach to detect aneuploidies (atypical autosomal and sex chromosome karyotypes) in the ancient genetic record and distinguish such karyotypes from contamination. We confirm that aneuploidies can be detected even in low-coverage genomes ( ~ 0.0001-fold), common in ancient DNA. We apply this method to ancient skeletal remains from Britain to document the first instance of mosaic Turner syndrome (45,X0/46,XX) in the ancient genetic record in an Iron Age individual sequenced to average 9-fold coverage, the earliest known incidence of an individual with a 47,XYY karyotype from the Early Medieval period, as well as individuals with Klinefelter (47,XXY) and Down syndrome (47,XY, + 21). Overall, our approach provides an accessible and automated framework allowing for the detection of individuals with aneuploidies, which extends previous binary approaches. This tool can facilitate the interpretation of burial context and living conditions, as well as elucidate past perceptions of biological sex and people with diverse biological traits.
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Affiliation(s)
- Kyriaki Anastasiadou
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom.
| | - Marina Silva
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Thomas Booth
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Leo Speidel
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
- Genetics Institute, University College London, London, United Kingdom
| | | | - Christopher Barrington
- Bioinformatics and Biostatistics Science Technology Platform, The Francis Crick Institute, London, United Kingdom
| | - Jo Buckberry
- School of Archaeological and Forensic Sciences, University of Bradford, Bradford, United Kingdom
| | | | - Ben Ford
- Oxford Archaeology, Oxford, United Kingdom
| | | | - Alexandre Gilardet
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Isabelle Glocke
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Keefe
- York Osteoarchaeology, York, United Kingdom
- On-Site Archaeology, York, United Kingdom
| | - Monica Kelly
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Mackenzie Masters
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Jesse McCabe
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Paola Ponce
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | | | - Jordi Ruiz Ventura
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Pooja Swali
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Frankie Tait
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Helen Webb
- Oxford Archaeology, Oxford, United Kingdom
| | - Mia Williams
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Malin Holst
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Louise Loe
- Oxford Archaeology, Oxford, United Kingdom
| | - Ian Armit
- Department of Archaeology, University of York, York, United Kingdom
| | - Rick Schulting
- School of Archaeology, University of Oxford, Oxford, United Kingdom
| | - Pontus Skoglund
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom.
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17
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Kouri C, Sommer G, Martinez de Lapiscina I, Elzenaty RN, Tack LJW, Cools M, Ahmed SF, Flück CE. Clinical and genetic characteristics of a large international cohort of individuals with rare NR5A1/SF-1 variants of sex development. EBioMedicine 2024; 99:104941. [PMID: 38168586 PMCID: PMC10797150 DOI: 10.1016/j.ebiom.2023.104941] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Steroidogenic factor 1 (SF-1/NR5A1) is essential for human sex development. Heterozygous NR5A1/SF-1 variants manifest with a broad range of phenotypes of differences of sex development (DSD), which remain unexplained. METHODS We conducted a retrospective analysis on the so far largest international cohort of individuals with NR5A1/SF-1 variants, identified through the I-DSD registry and a research network. FINDINGS Among 197 individuals with NR5A1/SF-1 variants, we confirmed diverse phenotypes. Over 70% of 46, XY individuals had a severe DSD phenotype, while 90% of 46, XX individuals had female-typical sex development. Close to 100 different novel and known NR5A1/SF-1 variants were identified, without specific hot spots. Additionally, likely disease-associated variants in other genes were reported in 32 individuals out of 128 tested (25%), particularly in those with severe or opposite sex DSD phenotypes. Interestingly, 48% of these variants were found in known DSD or SF-1 interacting genes, but no frequent gene-clusters were identified. Sex registration at birth varied, with <10% undergoing reassignment. Gonadectomy was performed in 30% and genital surgery in 58%. Associated organ anomalies were observed in 27% of individuals with a DSD, mainly concerning the spleen. Intrafamilial phenotypes also varied considerably. INTERPRETATION The observed phenotypic variability in individuals and families with NR5A1/SF-1 variants is large and remains unpredictable. It may often not be solely explained by the monogenic pathogenicity of the NR5A1/SF-1 variants but is likely influenced by additional genetic variants and as-yet-unknown factors. FUNDING Swiss National Science Foundation (320030-197725) and Boveri Foundation Zürich, Switzerland.
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Affiliation(s)
- Chrysanthi Kouri
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland; Department for BioMedical Research, University of Bern, Bern 3008, Switzerland; Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern 3012, Switzerland
| | - Grit Sommer
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland; Department for BioMedical Research, University of Bern, Bern 3008, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Switzerland, University of Bern, Bern 3012, Switzerland
| | - Idoia Martinez de Lapiscina
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland; Department for BioMedical Research, University of Bern, Bern 3008, Switzerland; Research into the Genetics and Control of Diabetes and Other Endocrine Disorders, Biobizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Spain; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid 28029, Spain; CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid 28029, Spain; Endo-ERN, Amsterdam 1081 HV, the Netherlands
| | - Rawda Naamneh Elzenaty
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland; Department for BioMedical Research, University of Bern, Bern 3008, Switzerland; Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern 3012, Switzerland
| | - Lloyd J W Tack
- Department of Paediatric Endocrinology, Department of Paediatrics and Internal Medicine, Ghent University Hospital, Ghent University, Ghent 9000, Belgium
| | - Martine Cools
- Department of Paediatric Endocrinology, Department of Paediatrics and Internal Medicine, Ghent University Hospital, Ghent University, Ghent 9000, Belgium
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Sick Children, Glasgow G51 4TF, UK
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland; Department for BioMedical Research, University of Bern, Bern 3008, Switzerland.
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18
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Mediå LM, Sigurdardottir S, Fauske L, Waehre A. Understanding sexual health concerns among adolescents and young adults with differences of sex development: a qualitative study. Int J Qual Stud Health Well-being 2023; 18:2204635. [PMID: 37092307 PMCID: PMC10128427 DOI: 10.1080/17482631.2023.2204635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/14/2023] [Indexed: 04/25/2023] Open
Abstract
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.
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Affiliation(s)
- Line Merete Mediå
- Women and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Solrun Sigurdardottir
- Women and Children’s Division, Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
| | - Lena Fauske
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Anne Waehre
- Department of Child and Adolescent Psychiatry, Oslo University Hospital and Institute of Clinical Medicine, Oslo, Norway
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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19
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Nathaniel S, Oleru O, Seyidova N, Levy L, Taub PJ, Horesh E. Vaginal Reconstruction in the Pediatric Population: An Analysis of a National Database. J Pediatr Surg 2023; 58:2405-2409. [PMID: 37633769 PMCID: PMC11000433 DOI: 10.1016/j.jpedsurg.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE In the pediatric population, vaginoplasties can be performed in patients with either congenital malformations or acquired conditions. To our knowledge, there has been no study to date investigating the outcomes of vaginoplasty in the pediatric population using a nationwide database. Here, we present a national cohort study of perioperative characteristics and 30-day complications of vaginoplasty in pediatric patients. METHODS A level II retrospective, prognosis cohort study was performed using the Pediatric National Surgical Quality Improvement Program (NSQIP-P) database from 2012 to 2020. Data from patients age 0 to 18 who underwent vaginoplasty was queried using CPT code 57,335. Descriptive analysis was performed to elucidate patterns in patient demographics, perioperative characteristics, and 30-day postoperative outcomes. RESULTS A total of 183 patients were identified. Median age was 2.41 years (IQR 0.9 to 12.1). In this population, 58.5% of patients had ASA class 2, and 33.3% ASA class 3. Congenital malformation was present in 75.9%. Average total length of stay was 2.7 days (SD = 3.8) and readmission rate was 7.86%. Complications included urinary tract infection (3.3%), bleeding/transfusions (2.2%), organ/space surgical site infection (1.1%), and superficial incisional surgical site infection (0.6%). The most common procedures performed simultaneously with vaginoplasty included cystourethroscopy (n = 66), clitoroplasty for intersex state (n = 58), and plastic repair of introitus (n = 22). CONCLUSION Vaginoplasties in the pediatric population were found to have low rates of 30-day readmission and low incidence of 30-day postoperative complications. Further studies focusing on prospective clinical data related to pediatric vaginoplasty can help identify factors to improve long-term outcomes in this population.
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Affiliation(s)
- Sarah Nathaniel
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Olachi Oleru
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Nargiz Seyidova
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Lior Levy
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Peter J Taub
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Elan Horesh
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
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20
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Hunter SK, S Angadi S, Bhargava A, Harper J, Hirschberg AL, D Levine B, L Moreau K, J Nokoff N, Stachenfeld NS, Bermon S. The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine. Med Sci Sports Exerc 2023; 55:2328-2360. [PMID: 37772882 DOI: 10.1249/mss.0000000000003300] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
ABSTRACT Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.
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Affiliation(s)
- Sandra K Hunter
- Exercise Science Program, Department of Physical Therapy, and Athletic and Human Performance Center, Marquette University, Milwaukee, WI
| | | | - Aditi Bhargava
- Department of Obstetrics and Gynecology, Center for Reproductive Sciences, University of California, San Francisco, CA
| | - Joanna Harper
- Loughborough University, Loughborough, UNITED KINGDOM
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, SWEDEN
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, and the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kerrie L Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, and Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, CO
| | - Natalie J Nokoff
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nina S Stachenfeld
- The John B. Pierce Laboratory and Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Stéphane Bermon
- Health and Science Department, World Athletics, Monaco and the LAMHESS, University Côte d'Azur, Nice, FRANCE
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21
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Wang JC, Dalke KB, Nachnani R, Baratz AB, Flatt JD. Medical Mistrust Mediates the Relationship Between Nonconsensual Intersex Surgery and Healthcare Avoidance Among Intersex Adults. Ann Behav Med 2023; 57:1024-1031. [PMID: 37616560 DOI: 10.1093/abm/kaad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Intersex individuals experience poor health due, in part, to healthcare avoidance. Nonconsensual intersex surgery may contribute to medical mistrust and avoidance among intersex populations. PURPOSE The purpose of this study was to explore the relationship between nonconsensual surgery and healthcare avoidance among intersex populations and to examine if medical mistrust mediates this relationship. METHODS Data for this cross-sectional study were collected in 2018 and analyzed in 2022. Participants completed a survey collecting information on demographics, medical mistrust, history of nonconsensual surgery, and history of postponing healthcare. One hundred nine participants with valid responses to all regression model variables were included in the study. Multivariable logistic regression models controlling for age, race, and income, examined the relationship between nonconsensual surgery and postponing preventive and emergency healthcare. Mediation analyses of cross-sectional data examined whether medical mistrust mediated the relationship between nonconsensual surgery and postponing preventive and emergency healthcare. RESULTS Mean medical mistrust score was 2.8 (range = 1-4; standard deviation = 0.8), 49.7% of participants had nonconsensual surgery in their lifetime, 45.9% postponed emergency healthcare, and 61.5% postponed preventive healthcare in their lifetime. Nonconsensual surgery was associated with increased odds of delaying preventive (adjusted odds ratio [AOR] = 4.17; confidence interval [CI] = 1.76-9.88; p = .016) and emergency healthcare (AOR = 4.26; CI = 1.71-10.59; p = .002). Medical mistrust mediated the relationship between nonconsensual surgery and delaying preventive (indirect effect = 1.78; CI = 1.16-3.67) and emergency healthcare (indirect effect = 1.66; CI = 1.04-3.30). CONCLUSIONS Nonconsensual surgery contributed to healthcare avoidance in this intersex population by increasing medical mistrust. To decrease healthcare avoidance, intersex health promotion interventions should restrict nonconsensual surgery and build trust through trauma-informed care.
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Affiliation(s)
- Jeremy C Wang
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Katharine B Dalke
- Department of Psychiatry and Behavioral Health, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Rahul Nachnani
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | | | - Jason D Flatt
- Department of Social & Behavioral Sciences, University of Nevada, Las Vegas, Las Vegas, NV, USA
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22
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Balagamage C, Arshad A, Elhassan YS, Ben Said W, Krone RE, Gleeson H, Idkowiak J. Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care. Clin Endocrinol (Oxf) 2023. [PMID: 37964596 DOI: 10.1111/cen.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.
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Affiliation(s)
- Chamila Balagamage
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Amynta Arshad
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- The Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Wogud Ben Said
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth E Krone
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Idkowiak
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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23
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Walser J, Hochleitner M, Komlenac N. Support for affirmative actions to increase inclusivity of intersex* persons at an Austrian medical university. BMC MEDICAL EDUCATION 2023; 23:825. [PMID: 37924071 PMCID: PMC10623750 DOI: 10.1186/s12909-023-04830-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 11/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Since the ruling handed down by the Austrian Constitutional Court in 2018 intersex variation has been recognized under Austrian law as a "third sex". In order to ensure that people with intersex variation are not discriminated against based on their group membership affirmative actions (i.e., proactive practices to avert discrimination) can be implemented. The current study explored whether students and employees at an Austrian medical university know about intersex variation. Furthermore, the study investigated what affirmative actions are practiced at the medical university to be inclusive for intersex persons and students' and employees' support for such affirmative actions. METHODS All students and employees of a medical university in Austria were invited by e-mail to participate at the current study that included a self-constructed knowledge test on intersex variation with ten true-false questions. On five-point Likert scales participants reported for each of twelve listed affirmative actions whether they had seen a certain affirmative action at their university and how important they thought the implementation of an affirmative action was. Finally, participants' gender, age, sexual orientation, highest level of education, and nationality was assessed. A cluster analysis was performed to determine groups of people with different degrees of support for affirmative actions for intersex persons. RESULTS 220 students (62% cisgender women, 38% cisgender men) and 200 employees (72% cisgender women, 28% cisgender men) participated. Participants responded correctly to three out of ten knowledge test questions. The cluster analysis revealed that participants could be clustered as heterosexual cisgender women (Cluster 1; 55%), heterosexual cisgender men (Cluster 2; 30%), or sexual minority cisgender women and men (Cluster 3; 15%). Sexual minority persons knew more about intersex variation than did heterosexual participants. On average, affirmative actions for the inclusivity of intersex people have not been encountered (M = 1.5, SD = 0.4) at the studied university. Participants, especially those in Cluster 3, believed that the listed actions are moderately important. CONCLUSIONS At the medical university many actions should be taken to increase inclusivity for intersex people. Increasing the knowledge of university staff and students concerning intersex might help increase their support for such actions.
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Affiliation(s)
- Judith Walser
- Gender Medicine Unit, Medical University of Innsbruck, Innsbruck, 6020, Austria
- Faculty of Business and Management, University of Innsbruck, Innsbruck, Austria
| | | | - Nikola Komlenac
- Gender Medicine Unit, Medical University of Innsbruck, Innsbruck, 6020, Austria.
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24
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Cursino KA, Garcia GM, Barros BA, Mazzola TN, Fabbri-Scallet H, Guaragna MS, Vieira TAP, Mello MPD, Maciel-Guerra AT, Guerra-Junior G. Prenatal Findings in Postnatal Cases of Disorders of Sex Development: Experience from a Tertiary-Specialized Center in Brazil. Fetal Diagn Ther 2023; 51:49-54. [PMID: 37793360 DOI: 10.1159/000534401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION AND OBJECTIVE Prenatal suspicion of disorders/differences of sex development (DSDs) is a relatively new phenomenon. The aim of this study was to review the prenatal findings of DSD cases postnatally diagnosed in our tertiary referral center. METHODS We evaluated 57 DSD cases with sex ambiguity who had undergone prenatal ultrasound with phenotypic sex assessment and/or cell-free fetal DNA (cffDNA) for genotypic sex assessment. RESULTS Prenatal cffDNA had been performed in 32 cases, being positive (suggestive of male genotypic sex) in 26 and negative (suggestive of female genotypic sex) in 6. Five with cffDNA negative had a prenatal ultrasound indicating female external genitalia, in turn, in those with cffDNA positive, only two had a prenatal ultrasound indicating male external genitalia. Our postnatal data showed that when external genitalia were female or poorly virilized, prenatal ultrasound indicated female sex, but in cases of higher degree of virilization, ultrasound showed similar rates of male, female, or undetermined sex. Regarding the karyotype, our data showed those with XY karyotype had positive cffDNA, those with XX karyotype had negative cffDNA, and all five with sex chromosome anomalies had positive cffDNA because they were 45,X/46,XY. We suggested an algorithm to investigate these cases during gestation, including evaluation of uterus, fetal growth, and malformations. CONCLUSION We suggest that the parents should be counseled prenatally by a dedicated multidisciplinary team with experience in DSD management and evaluated as soon as possible after birth.
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Affiliation(s)
- Kleber Andrade Cursino
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Guilherme Mantelato Garcia
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Beatriz Amstalden Barros
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tais Nitsch Mazzola
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Helena Fabbri-Scallet
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Mara Sanches Guaragna
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tarsis Antonio Paiva Vieira
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Maricilda Palandi de Mello
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
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25
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Das DV, Jabbar PK, Gomez R, Nambisan B, Bhuvitha MS, Nair A, Jayakumari C. Prevalence, distribution, and risk markers for the development of gonadal germ cell tumors in patients with certain types of disorders of sexual differentiation with Y chromosome - A retrospective study. Indian J Cancer 2023; 60:464-474. [PMID: 38078466 DOI: 10.4103/ijc.ijc_1218_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/04/2021] [Indexed: 01/24/2024]
Abstract
PURPOSE To study the prevalence, subtypes, and risk markers for the development of gonadal germ cell tumors (GCT's) among disorders of sexual differentiation (DSD) patients with the Y chromosome. MATERIALS AND METHOD Design: A retrospective review of the patient's case records from 2010 to 2020 in Government Medical College, Thiruvananthapuram, India was studied. The study participants included 54 subjects with DSD containing the Y chromosome. Demographic data, external masculinization scoring, associated congenital anomalies, karyotyping, intraoperative findings such as gonadal location and internal genital ducts, histopathology of the resected gonads, and its immunohistochemistry were collected. The prevalence of gonadal GCT's was estimated from paraffin-embedded gonadectomy samples (S = 82). RESULTS The median age of occurrence of gonadal GCT's was 18 years. The prevalence of malignant gonadal GCT's was highest among the PAIS group (19.2%) followed by gonadal dysgenesis (15.8% each in MGD and CGD) and least among CAIS (7.7%) (p < 0.01). The most common type of malignant gonadal GCT's in the descending order of frequency was dysgerminoma, seminoma, mixed GCT, and yolk sac tumor. Multivariance logistic analysis showed post-puberty and the presence of congenital anomalies were associated with the occurrence of gonadal GCT's ( P < 0.01). CONCLUSION The overall prevalence of gonadal GCT's (malignant and premalignant) among DSD with Y chromosomes is nearly 25%. Dysgerminoma is the most common malignant gonadal GCT's. Age at or above 18 years and the presence of congenital anomalies like renal agenesis, retroperitoneal vascular defects, and congenital diaphragmatic hernia were independent risk markers for the development of gonadal GCT's.
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Affiliation(s)
- Darvin V Das
- Department of Endocrinology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - P K Jabbar
- Department of Endocrinology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - Ramesh Gomez
- Department of Endocrinology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - Bindu Nambisan
- Department of Obstetrics and Gynecology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - M S Bhuvitha
- Department of Pathology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - Abilash Nair
- Department of Endocrinology, Government Medical College, Thiruvanathapuram, Kerala, India
| | - C Jayakumari
- Department of Endocrinology, Government Medical College, Thiruvanathapuram, Kerala, India
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26
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Priyadarshini S, Sharma R. Disorders of Sex Development in Office Practice. Indian J Pediatr 2023; 90:1030-1037. [PMID: 37354346 DOI: 10.1007/s12098-023-04640-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/24/2023] [Indexed: 06/26/2023]
Abstract
Disorders of sex development (DSD) is a broad term for congenital conditions with a discrepancy in chromosomal, gonadal, or anatomic sex. Pediatricians are often faced with the challenge of managing a newborn/infant with atypical genitalia or an older child with disordered puberty, which come under the purview of DSD. This article provides an update for pediatricians on comprehensive approach to DSD with a focus on atypical genitalia.
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Affiliation(s)
- Sukanya Priyadarshini
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Room No. 830, Mother and Child Block, New Delhi, 110029, India
| | - Rajni Sharma
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Room No. 830, Mother and Child Block, New Delhi, 110029, India.
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27
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Gold S, Huang C, Radi R, Gupta P, Felner EI, Haw JS, Childress K, Sokkary N, Tangpricha V, Goodman M, Yeung H. Dermatologic care of patients with differences of sex development. Int J Womens Dermatol 2023; 9:e106. [PMID: 37671254 PMCID: PMC10473340 DOI: 10.1097/jw9.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 08/01/2023] [Indexed: 09/07/2023] Open
Abstract
Background Differences of sex development (DSD or disorders of sex development) are uncommon congenital conditions, characterized by atypical development of chromosomal, gonadal, or anatomic sex. Objective Dermatologic care is an important component of the multidisciplinary care needed for individuals with DSD. This article discusses the most common primary dermatologic manifestations of DSD in addition to the cutaneous manifestations of hormonal and surgical therapies in individuals with DSD. Data sources Published articles including case series and case reports on PubMed. Study selections Selection was conducted by examining existing literature with a team of multidisciplinary specialists. Methods Narrative review. Limitations This article was not conducted as a systematic review. Results In Klinefelter syndrome, refractory leg ulcers and incontinentia pigmenti have been described. Turner syndrome is associated with lymphatic malformations, halo nevi, dermatitis, and psoriasis. Virilization can be seen in some forms of congenital adrenal hyperplasia, where acne and hirsutism are common. Conclusion Dermatologists should consider teratogenic risk for treatments of skin conditions in DSD depending on pregnancy potential. Testosterone replacement, commonly used for Klinefelter syndrome, androgen insensitivity syndrome, 5-alpha reductase deficiency, gonadal dysgenesis, or ovotesticular DSD, may cause acne.
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Affiliation(s)
- Sarah Gold
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Christina Huang
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Rakan Radi
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Pranav Gupta
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Eric I. Felner
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jeehea Sonya Haw
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Krista Childress
- Pediatric and Adolescent Gynecology, University of Utah, Primary Children’s Hospital, Salt Lake City, Utah
| | - Nancy Sokkary
- Pediatric and Adolescent Gynecology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Goodman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
- Clinical Resource Hub, Veterans Administration Veterans Integrated Service Network 7 Southeast Network, Decatur, Georgia
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28
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Shen H, Liu Y, Wang C, Wang R, Di Z, Huang X, Zhang H, Liu M. Prenatal diagnosis of 46,XX testicular disorder of sex development with SRY-positive: A case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2023; 289:140-144. [PMID: 37660509 DOI: 10.1016/j.ejogrb.2023.08.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/30/2023] [Indexed: 09/05/2023]
Abstract
We report a case of a fetus with 46,XX testicular disorder of sex development detected prenatally. This fetus was found abnormally due to non-invasive prenatal testing. Amniocentesis revealed SRY gene on the X chromosome of the fetus. The related literature was reviewed, and the advantages and limitations of various prenatal diagnostic techniques were discussed. The combination of non-invasive prenatal testing and various prenatal diagnostic techniques has enabled more fetuses with sex reversal to be detected.
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Affiliation(s)
- Huimin Shen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Yu Liu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Chao Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Ruijing Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Zhixin Di
- Department of Ultrasonic Medicine, The Second Affiliated Hospital of Harbin Medical University, China
| | - Xin Huang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Haomiao Zhang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China
| | - Meimei Liu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Harbin Medical University, China.
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29
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Gabriele A, Chierto E, Gino S, Inturri S, Aneli S, Robino C. Privacy and ethical challenges of the Amelogenin sex test in forensic paternity/kinship analysis: Insights from a 13-year case history. Forensic Sci Int Synerg 2023; 7:100440. [PMID: 37840559 PMCID: PMC10568343 DOI: 10.1016/j.fsisyn.2023.100440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 09/07/2023] [Accepted: 09/14/2023] [Indexed: 10/17/2023]
Abstract
The Amelogenin sex test included in forensic DNA typing kits has the potential to identify congenital conditions such as differences/disorders of sex development (DSD). It can also reveal mismatches between genotypic sex and gender marker in identity documents of transgender persons who obtained legal gender recognition. In a 13-year case history of paternity/kinship tests, involving n = 962 females and n = 1001 males, two mismatches between Amelogenin sex test (male) and gender marker (female), and three cases of chromosomal DSD (Klinefelter syndrome) were observed. The concrete risk of observing Amelogenin anomalies, their potential causes, and the context in which they occur (forensic, i.e. non-medical) mean that laboratory operators are called to strike a complex balance between privacy interests and individual health rights when providing preliminary information and reporting Amelogenin incidental findings. This case history argues for the need of a more responsible approach towards the Amelogenin sex test in the forensic community.
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Affiliation(s)
- Alessandro Gabriele
- Department of Public Health Sciences and Pediatrics, University of Turin, C.so Galileo Galilei 22, 10126, Turin, Italy
| | - Elena Chierto
- Department of Public Health Sciences and Pediatrics, University of Turin, C.so Galileo Galilei 22, 10126, Turin, Italy
| | - Sarah Gino
- Department of Health Sciences, University of Eastern Piedmont, Via Solaroli 17, 28100, Novara, Italy
| | - Serena Inturri
- Department of Public Health Sciences and Pediatrics, University of Turin, C.so Galileo Galilei 22, 10126, Turin, Italy
| | - Serena Aneli
- Department of Public Health Sciences and Pediatrics, University of Turin, C.so Galileo Galilei 22, 10126, Turin, Italy
| | - Carlo Robino
- Department of Public Health Sciences and Pediatrics, University of Turin, C.so Galileo Galilei 22, 10126, Turin, Italy
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30
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Jelley H, Meder M, Timme K. Virilization at Puberty: A Rare Cause. Clin Pediatr (Phila) 2023; 62:946-950. [PMID: 36797848 DOI: 10.1177/00099228221146508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Hannah Jelley
- Division of Pediatric Diabetes & Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Primary Children's Hospital, Salt Lake City, UT, USA
| | - Michelle Meder
- Division of Pediatric Diabetes & Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Primary Children's Hospital, Salt Lake City, UT, USA
| | - Kathleen Timme
- Division of Pediatric Diabetes & Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Primary Children's Hospital, Salt Lake City, UT, USA
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31
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Yu Y, Lee PA, Huerta-Saenz L, Allen NG. A Novel Variant in NR5A1 Presenting as 46,XY Difference of Sex Development. JCEM CASE REPORTS 2023; 1:luad103. [PMID: 37719339 PMCID: PMC10502515 DOI: 10.1210/jcemcr/luad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Indexed: 09/19/2023]
Abstract
Differences of sex development (DSDs) are a spectrum of congenital clinical conditions involving the development of gonadal, chromosomal, and anatomical sex. The physical presentation provides incomplete clues because underlying etiologies may present with similar findings. We describe an 8-year-old boy from the Dominican Republic originally diagnosed with congenital adrenal hyperplasia (CAH). He was prescribed oral hydrocortisone and fludrocortisone, with irregular adherence. During infancy, he had human chorionic gonadotropin injections to stimulate phallic growth. After migrating to the United States, medications became depleted but without adrenal crisis. Laboratory testing with high-dose adrenocorticotropin stimulation study ruled out CAH. Careful examination noted an underdeveloped bifid scrotum, bilaterally undescended testicles, a 2-cm phallus, severe penoscrotal hypospadias, and chordee. Subsequently, he had a 2-stage bilateral orchiopexy and surgical repair of penoscrotal hypospadias and chordee. Genetic testing for 46,XY DSD revealed a novel, dominant, heterozygous, likely pathogenic variant (c.102 + 1G > C) in the NR5A1 gene associated with severe phenotype of undervirilized male. This case illustrates the crucial role of molecular genetic testing for the diagnosis of 46,XY DSDs and a novel NR5A1 gene variant.
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Affiliation(s)
- Yunting Yu
- Penn State College of Medicine, Hershey, PA 17033, USA
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA 17033, USA
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Lina Huerta-Saenz
- Penn State College of Medicine, Hershey, PA 17033, USA
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Natalie G Allen
- Penn State College of Medicine, Hershey, PA 17033, USA
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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32
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Johnson EK, Whitehead J, Cheng EY. Differences of Sex Development: Current Issues and Controversies. Urol Clin North Am 2023; 50:433-446. [PMID: 37385705 DOI: 10.1016/j.ucl.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Differences of sex development (DSD) encompass a broad range of conditions in which the development of chromosomal, gonadal, or anatomic sex is not typically male or female. Terms used to describe DSD are controversial, and continuously evolving. An individualized, multidisciplinary approach is key to both the diagnosis and management of DSD. Recent advances in DSD care include expanded genetic testing options, a more nuanced approach to gonadal management, and an emphasis on shared decision-making, particularly related to external genital surgical procedures. The timing of DSD surgery is currently being questioned and debated in both medical and advocacy/activism spheres.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA.
| | - Jax Whitehead
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 86, Chicago, IL 60611, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA
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Hannema SE, Wolffenbuttel KP, van Bever Y, Brüggenwirth HT, van den Berg SAA, Hersmus R, Oosterhuis JW, Looijenga LHJ. Undetectable anti-Mullerian hormone and inhibin B do not preclude the presence of germ cell tumours in 45,X/46,XY or 46,XY gonadal dysgenesis. Clin Endocrinol (Oxf) 2023; 99:58-63. [PMID: 36905105 DOI: 10.1111/cen.14909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Individuals with 45,X/46,XY or 46,XY gonadal dysgenesis are at increased risk of germ cell malignancies. Therefore, prophylactic bilateral gonadectomy is advised in girls and considered in boys with atypical genitalia for undescended, macroscopically abnormal gonads. However, severely dysgenetic gonads may not contain germ cells rendering gonadectomy unnecessary. Therefore, we investigate if undetectable preoperative serum anti-Müllerian hormone (AMH) and inhibin B can predict the absence of germ cells, (pre)malignant or otherwise. DESIGN, PATIENTS AND MEASUREMENTS Individuals who had undergone bilateral gonadal biopsy and/or gonadectomy because of suspected gonadal dysgenesis in 1999-2019 were included in this retrospective study if preoperative AMH and/or inhibin B were available. Histological material was reviewed by an experienced pathologist. Haematoxylin and eosin and immunohistochemical stainings for SOX9, OCT4, TSPY and SCF (KITL) were used. RESULTS Thirteen males and 16 females were included, 20 with 46,XY and 9 with 45,X/46,XY DSD. Three females had dysgerminoma alongside gonadoblastoma; two gonadoblastoma, one germ cell neoplasia in situ (GCNIS) and three males had pre-GCNIS and/or pre-gonadoblastoma. Gonadoblastoma and/or dysgerminoma were present in 3/11 individuals with undetectable AMH and inhibin B, one of whom also had non-(pre)malignant germ cells. Of the other 18, in whom AMH and/or inhibin B were detectable, only one had no germ cells. CONCLUSIONS Undetectable serum AMH and inhibin B cannot reliably predict the absence of germ cells and germ cell tumours in individuals with 45,X/46,XY or 46,XY gonadal dysgenesis. This information should help in counselling about prophylactic gonadectomy, taking into account both the germ cell cancer risk and potential for gonadal function.
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Affiliation(s)
- Sabine E Hannema
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Katja P Wolffenbuttel
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Yolande van Bever
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hennie T Brüggenwirth
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, the Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Remko Hersmus
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J Wolter Oosterhuis
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leendert H J Looijenga
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Haghighat D, Berro T, Torrey Sosa L, Horowitz K, Brown-King B, Zayhowski K. Intersex people's perspectives on affirming healthcare practices: A qualitative study. Soc Sci Med 2023; 329:116047. [PMID: 37390680 DOI: 10.1016/j.socscimed.2023.116047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
Intersex people have variations in their sex characteristics that do not exclusively fall within binary definitions of male and female. This community experiences discrimination in the medical setting due to the pathologization of intersex bodies, including 'normalizing' genital surgeries without the child's consent. While research has explored biomedical aspects contributing to intersex variations, there is limited research centering intersex people's perspectives on their healthcare experiences. The aim of this qualitative study was to understand the experiences of intersex people in the medical setting, with the goal of providing recommendations to clinicians to promote affirming healthcare practices. Between November 2021 and March 2022 we conducted 15 virtual semi-structured interviews with members of the intersex community about their experiences with healthcare providers and perspectives on how their care could be improved. Participants were recruited through social media, with the majority residing in the United States. Through reflexive thematic analysis, 4 major themes were conceptualized: (1) the exclusion of intersex people in binary frameworks, (2) the common experience of medical trauma, (3) the value of psychosocial support, and (4) systemic change to address intersex healthcare. Recommendations were generated based on participants' narratives, including a recommendation for providers to use a trauma-informed approach to care. Healthcare providers must prioritize patient autonomy and ensure consent throughout their medical visits in order to promote intersex affirming care. Depathologization of intersex variations and comprehensive teachings of intersex history and medical care must be incorporated into medical curricula to mitigate experiences of medical trauma and to relieve the burden placed on patients to be their own medical experts and advocates. Participants shared the value of being connected to support groups and mental health resources. Systemic change is needed for the normalization and demedicalization of intersex variations and for the medical empowerment of the intersex community.
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Affiliation(s)
- Darius Haghighat
- Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA.
| | - Tala Berro
- MGH Institute of Health Professions, 36 1st Ave, Boston, MA 02129, USA.
| | - Lillian Torrey Sosa
- Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA.
| | - Kayla Horowitz
- McGill University, 845 Rue Sherbrooke O, Montréal, QC H3A 0G4, Canada; McGill University Health Centre, 1001 Bd Décarie, Montréal, QC H4A 3J1, Canada.
| | - Bria Brown-King
- interACT: Advocates for Intersex Youth, 365 Boston Post Road, Suite 163, Sudbury, MA 01776, USA.
| | - Kimberly Zayhowski
- Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA.
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de Oliveira FR, Mazzola TN, de Mello MP, Francese-Santos AP, Lemos-Marini SHVD, Maciel-Guerra AT, Hiort O, Werner R, Guerra-Junior G, Fabbri-Scallet H. DHX37 and NR5A1 Variants Identified in Patients with 46,XY Partial Gonadal Dysgenesis. Life (Basel) 2023; 13:life13051093. [PMID: 37240737 DOI: 10.3390/life13051093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
The group of disorders known as 46,XY gonadal dysgenesis (GD) is characterized by anomalies in testis determination, including complete and partial GD (PGD) and testicular regression syndrome (TRS). Several genes are known to be involved in sex development pathways, however approximately 50% of all cases remain elusive. Recent studies have identified variants in DHX37, a gene encoding a putative RNA helicase essential in ribosome biogenesis and previously associated with neurodevelopmental disorders, as a cause of PGD and TRS. To investigate the potential role of DHX37 in disorders of sexual development (DSD), 25 individuals with 46,XY DSD were analyzed and putative pathogenic variants were found in four of them. WES analyses were performed on these patients. In DHX37, the variant p.(Arg308Gln), recurrent associated with DSD, was identified in one patient; the p.(Leu467Val), predicted to be deleterious, was found together with an NR5A1 loss-of-function variant in patient 2; and, the p.(Val999Met) was identified in two unrelated patients, one of whom (patient 3) also carried a pathogenic NR5A1 variant. For both patients carrying DHX37 and NR5A1 pathogenic variants, a digenic inheritance is suggested. Our findings support the importance of DHX37 variants as a cause of disorders of sex development, implying a role in testis development.
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Affiliation(s)
- Felipe Rodrigues de Oliveira
- Center for Molecular Biology and Genetic Engineering (CBMEG), State University of Campinas (UNICAMP), Campinas 13083-875, Brazil
- Postgraduate Program in Child and Adolescent Health, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Taís Nitsch Mazzola
- Center for Investigation in Paediatric, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Maricilda Palandi de Mello
- Center for Molecular Biology and Genetic Engineering (CBMEG), State University of Campinas (UNICAMP), Campinas 13083-875, Brazil
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Ana Paula Francese-Santos
- Department of Translational Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Sofia Helena V de Lemos-Marini
- Department of Pediatrics, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
- Department of Translational Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, 23562 Lübeck, Germany
- Institute of Molecular Medicine, University of Lübeck, 23562 Lübeck, Germany
| | - Gil Guerra-Junior
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
- Department of Pediatrics, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
| | - Helena Fabbri-Scallet
- Center for Molecular Biology and Genetic Engineering (CBMEG), State University of Campinas (UNICAMP), Campinas 13083-875, Brazil
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
- Department of Translational Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, Brazil
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Weidler EM, Suorsa-Johnson KI, Baskin AS, Fagerlin A, Gardner MD, Rutter MM, Schafer-Kalkhoff T, van Leeuwen K, Sandberg DE. "It became easier once I knew": Stakeholder perspectives for educating children and teenagers about their difference of sex development. PATIENT EDUCATION AND COUNSELING 2023; 113:107763. [PMID: 37087875 DOI: 10.1016/j.pec.2023.107763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/05/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Secrecy about a child's difference of sex development (DSD) can lead to internalized shame and stigma. We explored how teenagers and adults with DSD, parents, healthcare providers, and allied professionals value and perceive patient education. METHODS Stakeholders (n = 110) completed qualitative semi-structured interviews. Relevant themes for educational content were queried and organized. RESULTS Education was consistently identified as essential to successful outcomes. There was less consistency in how to educate patients. Disagreement existed regarding who should champion the education process. Participants believed medically relevant information should be shared gradually with attention to developmental capacity. Details were lacking regarding how much or what information to share. Participants noted that vetted resources were helpful. Benefits of sharing condition-specific information with patients included supporting their psychosocial development. Barriers included parental resistance to sharing information due to shame/stigma, and cultural and/or family dynamics. CONCLUSIONS Stakeholders' different perspectives regarding patient DSD education warrant future research to focus on the design, evaluation, and implementation of education-focused interventions. PRACTICE IMPLICATIONS Healthcare providers are responsible for supporting the education of children and teenagers with DSD about their condition. When considering barriers, adopting a cultural or family systems framework can reduce parental resistance and promote open dialogue.
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Affiliation(s)
- Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - Kristina I Suorsa-Johnson
- Division of Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA.
| | - Alison S Baskin
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA; Veterans Administration Health Services Research and Development Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, USA
| | - Melissa D Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Meilan M Rutter
- Accord Alliance, USA; Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - David E Sandberg
- Accord Alliance, USA; Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA; Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Zhang D, Wang D, Tong Y, Li M, Meng L, Song Q, Xin Y. A novel c.64G > T (p.G22C) NR5A1 variant in a Chinese adolescent with 46,XY disorders of sex development: a case report. BMC Pediatr 2023; 23:182. [PMID: 37072715 PMCID: PMC10114376 DOI: 10.1186/s12887-023-03974-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/27/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Adolescents with 46,XY disorders of sex development (DSD) face additional medical and psychological challenges. To optimize management and minimize hazards, correct and early clinical and molecular diagnosis is necessary. CASE PRESENTATION We report a 13-year-old Chinese adolescent with absent Müllerian derivatives and suspected testis in the inguinal area. History, examinations, and assistant examinations were available for clinical diagnosis of 46,XY DSD. The subsequent targeting specific disease-causing genes, comprising 360 endocrine disease-causing genes, was employed for molecular diagnosis. A novel variation in nuclear receptor subfamily 5 group A member 1 (NR5A1) [c.64G > T (p.G22C)] was identified in the patient. In vitro functional analyses of the novel variant suggested no impairment to NR5A1 mRNA or protein expression relative to wild-type, and immunofluorescence confirmed similar localization of NR5A1 mutant to the cell nucleus. However, we observed decreased DNA-binding affinity by the NR5A1 variant, while dual-luciferase reporter assays showed that the mutant effectively downregulated the transactivation capacity of anti-Müllerian hormone. We described a novel NR5A1 variant and demonstrated its adverse effects on the functional integrity of the NR5A1 protein resulting in serious impairment of its modulation of gonadal development. CONCLUSIONS This study adds one novel NR5A1 variant to the pool of pathogenic variants and enriches the adolescents of information available about the mutation spectrum of this gene in Chinese population.
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Affiliation(s)
- Dan Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Dajia Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Yajie Tong
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Mingyu Li
- Department of Clinical Laboratory, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Lingzhe Meng
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Qiutong Song
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Ying Xin
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China.
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Peard LM, Morin J, Flores V, Graham K, Taylor AS, Pope JC, Halstead V, Cost NG, Roberts EM, Makari JH, Cranford W, Saltzman AF. Gonadal tumors in a contemporary cohort of patients with differences in sex development undergoing surgery - A multi-site study from the Pediatric Urologic Oncology Working Group of the societies for pediatric urology. J Pediatr Urol 2023:S1477-5131(23)00136-5. [PMID: 37117082 DOI: 10.1016/j.jpurol.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Disturbances in gonadal development lead to increased risk of gonadal malignancy in some but not all patients with differences in sex development (DSD). However, the natural history of these tumors is poorly described, and the literature remains sparse. OBJECTIVE The objective of this study was to describe the incidence of germ cell neoplasia in situ (GCNIS) and germ cell tumor (GCT) in a contemporary cohort of patients with DSD undergoing surgery and to provide long-term oncologic outcomes for these patients. STUDY DESIGN Patients with DSD who have undergone gonadectomy or gonadal biopsy were identified at four institutions. Clinical characteristics, pathology, and treatment details were obtained retrospectively. Patients were stratified into risk categories based on DSD diagnosis. Oncologic treatment and outcomes were recorded. Descriptive statistics are reported using parametric methods. RESULTS 83 patients were identified. Distribution of diagnoses is summarized in the summary table. 14 (16.9%) patients underwent gonadal biopsy, and 71 (85.5%) patients underwent gonadectomy (50/71 gonadectomies were bilateral). 8/83 (9.6%) patients had GCNIS or GCT (7 GCNIS, 1 GCT). Median age at surgery was 2.95 years (y) (interquartile range [IQR] 0.6-12.2) and 14y (IQR 0.85-16.9) in patients without and with GCNIS/GCT, respectively. All 8 patients with GCNIS/GCT had high or intermediate risk DSD diagnoses (4 mixed gonadal dysgenesis, 3 Turner with Y, 1 partial gonadal dysgenesis). Of the patients with high-risk diagnoses, 8/54 (15%) had GCNIS/GCT. No patient received adjuvant therapy, no patient had a recurrence, and all patients were living with mean follow up 6.4y. DISCUSSION The risk of gonadal malignancy is heterogeneous in the DSD population and can vary based on DSD diagnosis as well as maturation, testicularization, and location of the gonads. The most recent consensus recommendations on gonadal management emphasize risk stratification and consideration of gonadal surveillance based on gender of rearing, but supporting literature remains sparse. In this contemporary cohort of DSD patients who underwent gonadal surgery, most patients did not have evidence of adverse pathology, all patients with malignant or premalignant pathology had a high/intermediate risk DSD diagnosis, and all patients with GCNIS/GCT were treated with surgery alone without recurrence. CONCLUSIONS The distribution of patients with premalignant and malignant gonadal pathology and DSD in this cohort aligns with prior literature, and oncologic outcomes were excellent. These data add valuable information to the current literature and highlight the necessity to develop appropriate screening regimens for retained gonads.
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Affiliation(s)
- Leslie M Peard
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA; Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Jacqueline Morin
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Viktor Flores
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Kyle Graham
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Abby S Taylor
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - John C Pope
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Valeska Halstead
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Nicholas G Cost
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Evan M Roberts
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - John H Makari
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - Will Cranford
- Department of Biostatistics, College of Public Health, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Amanda F Saltzman
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
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López Soto Á, Bueno González M, Urbano Reyes M, Carlos Moya Jiménez L, Beltrán Sánchez A, Garví Morcillo J, Velasco Martínez M, Luis Meseguer González J, Martínez Rivero I, García Izquierdo O. Imaging in fetal genital anomalies. Eur J Obstet Gynecol Reprod Biol 2023; 283:13-24. [PMID: 36750003 DOI: 10.1016/j.ejogrb.2023.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
Genital anomalies are a heterogeneous group of congenital pathologies that have become increasingly relevant since the Chicago Consensus of 2005. Their postnatal diagnosis has developed significantly in the last two decades, while prenatal diagnosis seems to be underdeveloped, with few protocols available, fragmented scientific literature, and low diagnostic rates. This review aims to examine the current status of this subspecialty from the perspective of prenatal imaging. Indications for the evaluation of fetal genitalia can be divided into medical and non-medical reasons. Medical reasons include sex-linked disorders, detection of other anomalies, relevant family history, or multiple pregnancy. Non-medical reasons include parental request for sex disclosure. Disclosure of fetal sex may be associated with ethical, legal, and medical issues. The main imaging technology used is 2D ultrasound, although there are other complementary techniques such as 3D, MRI, or Color Doppler. Regarding working methodology, several authors have drawn attention to the lack of standardized protocols and guidelines. Most guidelines tend to limit their recommendations to study indications and ethical issues. Technical proposals, measurements, or working methods have not yet been standardized. Fetal sex determination is usually divided into early and late gestation. Early gestation is based on the sagittal sign. Late gestation is based on direct visualization. There are several measurements to describe male and female genitalia, such as penile length, bilabial diameter, or scrotal diameter. Prenatal diagnosis of genital pathologies presents some particularities such as the wide spectrum of phenotypes, the high frequency of associated deformities, or the time of diagnosis. Some of the most frequent pathologies are ambiguous genitalia, fetal sex discordance, hypospadias, micropenis, clitoromegaly, ovarian cysts, hydro(metro)colpos, and cloacal anomalies. Higher-quality studies and direction from scientific societies through the implementation of clinical guidelines are needed.
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Affiliation(s)
- Álvaro López Soto
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain.
| | | | - Maribel Urbano Reyes
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
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van de Grift TC. Condition openness is associated with better mental health in individuals with an intersex/differences of sex development condition: structural equation modeling of European multicenter data. Psychol Med 2023; 53:2229-2240. [PMID: 34663488 PMCID: PMC10123827 DOI: 10.1017/s0033291721004001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 07/16/2021] [Accepted: 09/14/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Openness on one's health condition or (stigmatized) identity generally improves mental health. Intersex or differences of sex development (DSD) conditions have long been kept concealed and high levels of (internalizing) mental health problems are reported. This study examines the effects of condition openness on anxiety and depression and the role of mediating concepts in this population. METHODS Cross-sectional data of individuals of 16 years and older with an intersex/DSD condition was collected in 14 specialized European clinics as part of the dsd-LIFE study. Patient-reported measures were taken on openness and shame (Coping with DSD), self-esteem (Rosenberg Self-Esteem Scale), satisfaction with care (CSQ4), anxiety and depression (HADS). Scores were compared per clinical group and data were analyzed via structural equation modeling (SEM) to calculate prediction and mediation models. RESULTS Data of 903 individuals were included in this study (Turner syndrome (n = 284), 46, XY DSD (n = 233), CAH (n = 206) and Klinefelter syndrome (n = 180)). Participants were moderately open on their condition. High levels of both anxiety and depression were observed across the sample. In SEM analysis, the tested models predicted 25% of openness, 31% of anxiety and 48% of depression. More condition openness directly predicted lower anxiety and depression symptoms, as well as indirectly through increased self-esteem, self-satisfaction and satisfaction with social support. CONCLUSIONS Condition openness is associated with lower anxiety and depression in individuals with an intersex/DSD condition. Healthcare may provide the necessary knowledge and skills to employ one's optimal level of self-disclosure in order to improve mental health.
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Affiliation(s)
- Tim C. van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (VUmc), Amsterdam, the Netherlands
- Department of Medical Psychology, Amsterdam UMC (VUmc), Amsterdam, the Netherlands
- Amsterdam Public Health Institute, Amsterdam, the Netherlands
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41
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Lee PA, Mazur T, Houk CP. DSD/intersex: historical context and current perspectives. J Pediatr Endocrinol Metab 2023; 36:234-241. [PMID: 36630604 DOI: 10.1515/jpem-2022-0582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/18/2022] [Indexed: 01/13/2023]
Abstract
Intersex/Disorders/Differences of sex development conditions have been recognized for millennia. An organized approach was adopted in the 1960-70s using the philosophy that gender identity was fluid and malleable. Consequences of this approach were the lack of disclosure, stigmatization, and excessive surgery to "normalize" the genitalia. Often this led to quality of life issues for those patients. There have been many modifications in approach since then to avoid the problems noted. There is consensus on many of these changes (e.g. disclosure) but continued controversy on others (e.g. the benefits of early surgery). This review summarizes the historical context and the current areas of consensus and controversy.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, State University of New York, John R. Oistei Children's Hospital, Buffalo, NY, USA
| | - Christopher P Houk
- Medical College of Georgia, Augusta University Medical Center, Augusta, GA, USA
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Wacharasindhu S, Ittiwut C, Ittiwut R, Aroonparkmongkol S, Suphapeetiporn K. A Novel NR5A1 Mutation in a Thai Boy with 46, XY DSD. J Pediatr Genet 2023. [DOI: 10.1055/s-0043-1764480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractDisorders of sex development (DSD) can be classified as 46,XX DSD, 46,XY DSD, and sex chromosome DSD. Several underlying causes including associated genes have been reported. Steroidogenic factor-1 is encoded by the NR5A1 gene, a crucial regulator of steroidogenesis in the growth of the adrenal and gonadal tissues. It has been discovered to be responsible for 10 to 20% of 46, XY DSD cases. Here, we described a 2-month-old infant who had ambiguous genitalia and 46, XY. Using whole exome sequencing followed by polymerase chain reaction–Sanger sequencing, a novel heterozygous nonsense c.1249C > T (p.Gln417Ter) variant in the NR5A1 gene was identified. It is present in his mother but absent in his father and maternal aunt and uncle. At the age of 7 months, the patient received a monthly intramuscular injection of low-dose testosterone for 3 months in a row. His penile length and diameter increased from 1.8 to 3 cm and from 0.8 to 1.3 cm, respectively. The patient also had normal adrenal reserve function by adrenocorticotropic hormone stimulation test. This study identified a novel causative p.Q417X (c.1249C > T) variant in NR5A1 causing 46,XY DSD in a Thai boy which is inherited from his unaffected mother.
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Affiliation(s)
- Suttipong Wacharasindhu
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chupong Ittiwut
- Central Laboratory, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rungnapa Ittiwut
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Department of Pediatrics, Center of Excellence for Medical Genomics, Medical Genomics Cluster, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suphab Aroonparkmongkol
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanya Suphapeetiporn
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Department of Pediatrics, Center of Excellence for Medical Genomics, Medical Genomics Cluster, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Weidler EM, Gardner M, Suorsa-Johnson KI, Schafer-Kalkhoff T, Rutter MM, Sandberg DE, van Leeuwen K. Surgical Decision-Making for Individuals with Differences of Sex Development: Stakeholders' views. FRONTIERS IN UROLOGY 2023; 3:1092256. [PMID: 37920724 PMCID: PMC10621752 DOI: 10.3389/fruro.2023.1092256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Advocacy and human rights organizations have called for a moratorium on elective surgical procedures until the patient is able to fully participate in the decision-making process. Due to the controversial nature surrounding surgery in differences of sex development (DSD) care, we aimed to assess the factors that teens and adults with DSD, parents, healthcare providers and other allied professionals consider pertinent to complex surgical decisions in DSD. Methods Stakeholders (n=110) in DSD care participated in semi-structured interviews exploring features and potential determinants of successful healthcare outcomes. Audio-recordings were transcribed, coded, and analyzed using qualitative data software. Codes for "Process of Decision-Making" and "Successful Outcome-Surgery/Appearance/Function" were further searched using keywords "surgery," "procedure," and "timing." Results Several themes were identified: 1) The nature or type of the decision being made; 2) Who should be involved in the decision-making process; 3) Timing of conversations about surgery; 4) Barriers to decision-making surrounding surgery; 5) The elements of surgical decision-making; and 6) The optimal approach to surgical decision-making. Many stakeholders believed children and adolescents with DSD should be involved in the process as developmentally appropriate. Conclusion DSD include a wide range of diagnoses, some of which may require urogenital reconstruction to relieve obstruction, achieve continence, and/or address other anatomical differences whether cosmetic or functional. Adolescents and adults with DSD desired autonomy and to be part of the decision-making process. Parents were divided in their opinion of who should be involved in making elective surgical decisions: the child or parents as proxy medical decision-makers. Providers and other professionals stressed the importance of process and education around surgical decisions. Ongoing research examines how decision-makers evaluate tradeoffs associated with decision options.
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Affiliation(s)
- Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s, Phoenix, Arizona
- Accord Alliance, USA
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center and Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kristina I. Suorsa-Johnson
- Division of Pediatric Psychology and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meilan M. Rutter
- Accord Alliance, USA
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David E. Sandberg
- Accord Alliance, USA
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center and Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children’s, Phoenix, Arizona
- Accord Alliance, USA
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Gardner M, Brinkman WB, Carley M, Liang N, Lightfoot S, Pinkelman K, Speiser PW, Schafer-Kalkhoff T, Suorsa-Johnson KI, VanderBrink B, Weidler EM, Wisniewski J, Stacey D, Sandberg DE. Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development. FRONTIERS IN UROLOGY 2023; 3:1089077. [PMID: 37920725 PMCID: PMC10621652 DOI: 10.3389/fruro.2023.1089077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support. Methods 34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted. Results Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information. Discussion Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.
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Affiliation(s)
- Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William B. Brinkman
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noi Liang
- Patient / parent / caregiver stakeholder partners, Denver, CO, USA
| | | | - Kendra Pinkelman
- Patient / parent / caregiver stakeholder partners, Ann Arbor, MI, USA
| | - Phyllis W. Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | | | - Brian VanderBrink
- Division of Urology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ
- Accord Alliance, USA
| | | | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
- Accord Alliance, USA
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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45
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Hegarty P, Smith A. Public understanding of intersex: an update on recent findings. Int J Impot Res 2023; 35:72-77. [PMID: 35031713 PMCID: PMC9935380 DOI: 10.1038/s41443-021-00485-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/17/2021] [Accepted: 10/14/2021] [Indexed: 11/08/2022]
Abstract
Surgical interventions on infants with intersex characteristics are considered justified by some on the grounds that they carry a high risk of intolerable stigma. However, public understanding of intersex and its medicalization are under-researched. We review recent qualitative and quantitative studies of the understandings of intersex and its medicalization among people who have no particular professional or public experience of intersex. First, such laypeople reason about clinical dilemmas by drawing on values in similar ways as expert healthcare professionals do. Second, laypeople can over-estimate the utility of current 'umbrella terms,' including intersex, for people with direct familial experience of intersex. Third, beliefs about good and bad effects of medical intervention are affected by framing intersex as either a medical condition or the natural basis for a social identity. Fourth, sexual identity is the best evidenced predictor of opinions about early surgical intervention and its legal limitation on human rights grounds. We argue that possible stigmatizing reactions from the public may not be a solid basis on which to justify early surgical intervention on intersex characteristics.
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46
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Hanna CA, Cummins A, Fox D. Babies born with ambiguous genitalia: Developing an educational resource for Australian midwives. Women Birth 2023; 36:e142-e149. [PMID: 35697608 DOI: 10.1016/j.wombi.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 01/25/2023]
Abstract
PROBLEM AND BACKGROUND The birth of a baby with ambiguous genitalia is rare and usually unexpected. Parents often receive inconsistent language from health-professionals after the birth. Initial interaction with the birth team has long-term consequences for families with babies born with ambiguous genitalia. AIM Understand the current practices on the day of birth and explore knowledge gaps for midwives regarding babies born with ambiguous genitalia. Develop educational content that can enable midwives to respond appropriately when the sex of a baby is unclear. METHODS This study included two phases, utilising qualitative descriptive research design with semi-structured interviews to understand the experiences of midwives caring for babies with ambiguous genitalia and their families. The findings informed the development a midwifery educational resource using these qualitative findings. FINDINGS Our analysis of 14 interviews with Australian midwives identified that they had no formal education to support families with a baby with ambiguous genitalia. Emotional support, advocacy and medical information translation were areas midwives perceived as essential skills to support these families. DISCUSSION Midwives provide a unique role in parental birth experiences. Themes that arose emphasised their psychosocial support role but lacked formal education and guidance on this topic. Midwives had learnt from the media about babies born with ambiguous genitalia and wanted evidence-based education to support parents. Midwife education focusing on both psychosocial and clinical care for parents and their baby with ambiguous genitalia is crucial. CONCLUSION Midwives can play a pivotal role in supporting parents with a baby with ambiguous genitalia. Themes from this qualitative study informed the development of a midwifery education digital resource.
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Affiliation(s)
- Chloe A Hanna
- Department of Gynaecology, Royal Children's Hospital, Melbourne, Australia; Reproductive Development Laboratory, Murdoch Children's Research Institute Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia.
| | - Allison Cummins
- Department of Midwifery, School of Nursing and Midwifery, College of Medicine, Health and Wellbeing, University of Newcastle, Australia
| | - Deborah Fox
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Australia
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47
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Liao LM, Baratz A. Medicalization of intersex and resistance: a commentary on Conway. Int J Impot Res 2023; 35:51-55. [PMID: 36076030 DOI: 10.1038/s41443-022-00597-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/09/2022]
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Ariyasu D, Nagamatsu F, Aso K, Akiba K, Hasegawa Y. Longitudinal clinical course in patients with 5α-reductase type 2 deficiency treated with testosterone and dihydrotestosterone during infancy and puberty. Endocr J 2023; 70:59-67. [PMID: 36216557 DOI: 10.1507/endocrj.ej22-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
5α-reductase type 2 (5αRD2) deficiency is a 46,XY disorder of sex development caused by impaired conversion of testosterone (T) to dihydrotestosterone (DHT). Penile enlargement therapy is important for male patients with 46,XY 5αRD2 deficiency who have undermasculinized external genitalia, such as severe micropenis. High-dose T and percutaneous DHT replacement are reportedly efficacious for penile enlargement in patients with this disorder. We presented herein the longitudinal course of four patients with 46,XY 5αRD2 deficiency who received T and DHT. T replacement therapy during infancy increased the stretched penile length (SPL) in three of the patients but was ineffective in one patient. DHT was administered to the three patients after T replacement therapy and further increased the SPL. During and after puberty, two patients asked for and received T replacement therapy, which contributed to increasing their SPL. A semen test in one patient with T replacement therapy at age 27 years revealed cryptozoospermia despite normal testicular volume. The clinical course of our patients during infancy indicated that DHT therapy may be preferrable to T replacement therapy for penile enlargement in patients with 5αRD2 deficiency. During and after puberty, T replacement therapy promoted penile enlargement possibly because of increased conversion of T to DHT via increased 5α-reductase type 1 activity even in patients in whom it was ineffective during infancy. In conclusion, DHT is effective for penile enlargement during infancy in patients with 5αRD2 deficiency while T replacement therapy is a viable option during puberty.
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Affiliation(s)
- Daisuke Ariyasu
- Department of Pediatrics, Kawasaki Municipal Hospital, Kanagawa 210-0013, Japan
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo 183-8561, Japan
| | - Fusa Nagamatsu
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo 183-8561, Japan
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto 860-8556, Japan
| | - Keiko Aso
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo 143-8541, Japan
| | - Kazuhisa Akiba
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo 183-8561, Japan
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo 183-8561, Japan
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Functional Assessment of a New PBX1 Variant in a 46,XY Fetus with Severe Syndromic Difference of Sexual Development through CRISPR-Cas9 Gene Editing. Genes (Basel) 2023; 14:genes14020273. [PMID: 36833200 PMCID: PMC9956894 DOI: 10.3390/genes14020273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Sexual development is a complex process relying on numerous genes. Disruptions in some of these genes are known to cause differences of sexual development (DSDs). Advances in genome sequencing allowed the discovery of new genes implicated in sexual development, such as PBX1. We present here a fetus with a new PBX1 NM_002585.3: c.320G>A,p.(Arg107Gln) variant, presenting with severe DSD along with renal and lung malformations. Using CRISPR-Cas9 gene editing on HEK293T cells, we generated a KD cell line for PBX1. The KD cell line showed reduced proliferation and adhesion properties compared with HEK293T cells. HEK293T and KD cells were then transfected plasmids coding either PBX1 WT or PBX1-320G>A (mutant). WT or mutant PBX1 overexpression rescued cell proliferation in both cell lines. RNA-seq analyses showed less than 30 differentially expressed genes, in ectopic mutant-PBX1-expressing cells compared with WT-PBX1. Among them, U2AF1, encoding a splicing factor subunit, is an interesting candidate. Overall, mutant PBX1 seems to have modest effects compared with WT PBX1 in our model. However, the recurrence of PBX1 Arg107 substitution in patients with closely related phenotypes calls for its impact in human diseases. Further functional studies are needed to explore its effects on cellular metabolism.
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50
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Franco M, Khorrami Chokami K, Albertelli M, Teti C, Cocchiara F, Gatto F, Trombetta C, Ferone D, Boschetti M. Modulatory activity of testosterone on growth pattern and IGF-1 levels in vanishing testis syndrome: a case report during 15 years of follow-up. BMC Endocr Disord 2023; 23:13. [PMID: 36631784 PMCID: PMC9835337 DOI: 10.1186/s12902-022-01258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The vanishing testis syndrome (VTS), is a 46, XY disorder of sex development (46, XY DSD) and is characterized by the absence of testis in a 46, XY subject with male genitalia, gonadal dysgenesis and consequent hypergonadotropic hypogonadism. CASE PRESENTATION A young man affected by VTS has been followed up for more than 15-year in our center. The patient received different testosterone formulations, which modulated his IGF-1 levels and height velocity, depending on different stimulatory effects, mimicking pubertal spurt until achieving a final height in line with his genetic target. Exogenous testosterone, activating GH/IGF-1 system, can directly influence growth pattern. With this particular case report we demonstrate that an accurate monitoring of patients with VTS, as well as a perfect reproduction of testosterone secretion during pubertal spurt, can guarantee a normal growth and development and, consequently, a high level of quality of life in adulthood. CONCLUSION Testosterone levels act an important role during pubertal spurt in modulating the GH/IGF-1 axis, besides its well-known impact in sexual development. Very little amount of exogenous testosterone can stimulate IGF-1 secretion and provide to growth velocity the drive that characterizes the initial phases of the growth spurt.
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Affiliation(s)
- Marta Franco
- Endocrinology Unit, UOSD Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Keyvan Khorrami Chokami
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Manuela Albertelli
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Claudia Teti
- Endocrinology, Diabetology and Metabolic Diseases Unit, ASL1, Imperia, Italy
| | | | - Federico Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlo Trombetta
- Department of Medicine, Surgery and Health Sciences, Urological Clinic, University of Trieste, Trieste, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy.
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