Establishing a molecular genetic diagnosis in children with Differences of Sex Development - a clinical approach

Phenotypic spectrum and long-term outcomes of patients with 46,XX disorders of sex development

PURPOSE

46,XX disorders of sex development (DSD) involve atypical genitalia accompanied by a normal female karyotype. This study was performed to investigate the clinical characteristics and long-term outcomes of patients with 46,XX DSD.

METHODS

The study included 34 patients with 46,XX DSD who presented with ambiguous genitalia or delayed puberty. Patients with congenital adrenal hyperplasia were excluded. Clinical phenotypes and overall outcomes were analyzed retrospectively.

RESULTS

Age at presentation ranged from birth to 40 years (median, 0.6 years), and the follow-up period ranged from 0.3 to 29.7 years (median, 8.8 years). Twenty patients were assigned female (58.8%). Etiologies included disorders of gonadal development (n=22), exogenous androgen exposure during pregnancy (n=5), association with syndromic disorders or genital anomalies (n=2), and unclassified causes (n=5). Ovotestis was the most frequent gonadal pathology (41.7%). Müllerian duct remnants were usually underdeveloped (52.9%) or absent (23.5%). Spontaneous puberty occurred in 17 of the 21 patients of pubertal age, while 9 patients required sex hormone replacement therapy. Gonadal complications were observed in 4 patients (gonadal tumors [n=3], and spontaneous gonadal rupture [n=1]), and gender dysphoria occurred in 1 patient who was assigned male.

CONCLUSION

This study described the wide phenotypic spectrum and pubertal outcome of patients with 46,XX DSD. Long-term multidisciplinary monitoring for pubertal development, fertility, gender identity, and gonadal complications is recommended.

Practice patterns in the care of proximal hypospadias among pediatric urologists

INTRODUCTION

About 25 % of patients with hypospadias have a proximal form, often associated with an underlying genetic cause or difference of sex development (DSD). Surgical complication/re-operation rates are high, surgical practice patterns are variable, and consensus recommendations to guide medical and surgical management are not yet available. One presumed barrier to consensus is understanding variability in management for this condition.

OBJECTIVE

To assess medical and surgical practice patterns of pediatric urologists regarding care of proximal hypospadias.

STUDY DESIGN

An anonymous, web-based survey was sent to members of the Societies for Pediatric Urology to capture medical and surgical management practices for patients with proximal hypospadias. Respondent demographics were obtained. Median estimated patients cared for per year was determined. Comparisons between those ≤50th percentile for volume and >50th percentile were made using chi squared and Fisher's exact tests.

RESULTS

137 completed surveys were returned (137/311 (44 %) opened emails), and 125 responses met inclusion criteria. Respondents were predominantly male (70 %), and practice in an urban (85 %), academic (72 %) setting. The median (IQR) estimated number of patients cared for per year was 7 (5.0, 10.0). Half (50 %) never receive referrals from other pediatric urologists for surgical care. Most never refer patients to other surgeons within (55 %) or outside (72 %) of their practice. Frequent independent ordering of a karyotype was reported, with less frequent ordering of hormonal and advanced genetic testing (Table). Performing systematic, post-operative data collection was reported infrequently (37 %). Those >50th percentile in volume compared to those ≤50th percentile reported receiving more referrals from other urologists for surgical care (any referrals received, 66 % vs 36 %, p = 0.001) and more commonly perform surgery independently (63 % vs 32 %, p = 0.003). There were no differences between groups regarding lab testing, medical specialty referrals, or surgical management.

DISCUSSION

Proximal hypospadias surgery is uncommonly performed by most pediatric urologists and patterns of independent lab evaluation and referral to medical subspecialities are variable. Few differences in practice were seen based on surgeon volume, especially around lab testing and medical specialty referrals. Though an optimal approach to medical evaluation is not yet defined, opportunities for greater uniformity in the management of proximal hypospadias exist. Clinical practice guidelines to help surgeons determine the best approach to medical evaluation and surgical management could improve quality of care in proximal hypospadias.

CONCLUSIONS

The approach to pre-operative medical care of patients with proximal hypospadias varies among pediatric urologists and is largely independent of surgeon operative volume.

Global perspective of psychosocial care of patients with differences of sex development from low-income countries

OBJECTIVE

Management of Differences of Sex Development (DSD) is complex and in resource limited settings the psychosexual and psychosocial aspects of DSD care have received limited attention. This review aims to explore recent literature on psychosocial care of DSD in low and upper middle-income countries (L/UMIC).

MATERIALS AND METHODS

Scientific databases were searched and papers on management of DSD were reviewed according to predefined inclusion criteria.

RESULTS

Papers published between January 2010 and July 2024 were screened for eligibility. Seventy studies specifically focusing on psychosexual and psychosocial aspects were identified. In these papers, the following aspects were studied in detail: gender identity, sexual behaviour, quality of life, perception of parents and society, communication and family counselling and socio-cultural and religious aspects.

CONCLUSIONS

The geographical distribution and volume of studies on the psychosexual and psychosocial aspects of DSD in L/UMIC are mostly originating from East-and South-Asia and South & Central America. The findings underscore the need for integrated and culturally sensitive interventions to support the psychosocial well-being of patients and their families affected by DSD within resource-limited contexts. We highly recommend providing specific guidelines recognising the socio-cultural milieu and resource restricted settings. International collaboration providing education and training should be encouraged.

Submicroscopic copy number variants in Indian children with gene panel negative 46, XY Gonadal Dysgenesis: An exploratory study using comparative genomic hybridization

BACKGROUND

46, XY disorders of sex development (DSD) are a group of highly heterogeneous conditions in which the molecular etiology remains unknown in a significant proportion of patients, even with massive parallel sequencing. Clinically significant copy number variants (CNVs) are identified in 20-30% of cases, particularly among those with gonadal dysgenesis (GD) and no molecular diagnosis.

METHODS

Fourteen patients with 46, XY DSD due to GD in whom no pathogenic/likely pathogenic variants were found on next-generation sequencing using a targeted panel of 155 genes were screened for clinically significant CNVs using Affymetrix Comparative Genomic Hybridization (CGH). Database of Chromosomal Imbalance and Phenotype in Humans using Ensembl Resources (DECIPHER) and ClinVar were searched for matching genotypes and phenotypes, and chromosomal regions were screened for genes with known or potential association with GD.

RESULTS

Significant CNVs were identified in 6 (43%) of 14 patients with 46, XY GD. A previously unreported 19p13.3 duplication was found in three patients. This CNV was associated with GD based on overlapping CNV regions from previous studies and databases; and the inclusion of CIRBP, a candidate gene implicated in GD. CNVs involving WT1 (11p15) and SOX8 (16p13.3) were also identified.

CONCLUSIONS

CGH was helpful in pointing toward the molecular etiology in a significant proportion of patients with "idiopathic" 46, XY GD. However, establishing causality will require additional evidence including functional studies.

Genomic testing for differences of sex development: Practices and perceptions of clinicians

OBJECTIVES

To investigate the approach taken by clinicians involved in the diagnosis and management of individuals with Differences of Sex Development (DSD), particularly with regard to genomic testing, and identify perceived gaps/strengths/barriers in current practice.

DESIGN AND METHODS

An anonymous online survey was developed, with questions exploring demographics, perceptions of genomic testing, availability of genetics services and opinions on the role and utility of genomic testing in DSD. All responses were anonymous. Clinicians involved in the diagnosis and management of individuals with DSD were recruited from relevant societies and departments across Australia and New Zealand.

RESULTS

79 eligible clinicians commenced the survey, with 63 completing it and 16 providing a partial response. The perceived benefit of having a genetic diagnosis for DSD was almost unanimous (97%). Almost half (48%) of respondents reported barriers in genomic testing. 81% of respondents reported they order genomic tests currently. Approaches to genomic testing when faced with four different clinical scenarios varied across respondents. Clinicians perceived genomic testing to be underutilised (median 36 on sliding scale from 0 to 100).

CONCLUSIONS

Despite 97% of respondents reporting benefit of a genetic diagnosis for individuals with DSD, this was not reflected throughout the survey with regard to clinical implementation. When faced with clinical scenarios, the recommendations for genomic testing from respondents was much lower, indicating the discrepancy between perception and clinical practice. Genomic testing in the context of DSD is seen as both beneficial and desired, yet there are multiple barriers impacting its integration into standard clinical care.

Assessment of testicular function in boys and adolescents

OBJECTIVE

The hypothalamic-pituitary-testicular axis is characterised by the existence of major functional changes from its establishment in fetal life until the end of puberty. The assessment of serum testosterone and gonadotrophins and semen analysis, typically used in the adult male, is not applicable during most of infancy and childhood. On the other hand, the disorders of gonadal axis have different clinical consequences depending on the developmental stage at which the dysfunction is established. This review addresses the approaches to evaluate the hypothalamic-pituitary-testicular axis in the newborn, during childhood and at pubertal age.

DESIGN

We focused on the hormonal laboratory and genetic studies as well as on the clinical signs and imaging studies that guide the aetiological diagnosis and the functional status of the gonads.

RESULTS

Serum gonadotrophin and testosterone determination is useful in the first 3-6 months after birth and at pubertal age, whereas AMH and inhibin B are useful biomarkers of testis function from birth until the end of puberty. Clinical and imaging signs are helpful to appraise testicular hormone actions during fetal and postnatal life.

CONCLUSIONS

The interpretation of results derived from the assessment of hypothalamic-pituitary-testicular in paediatric patients requires a comprehensive knowledge of the developmental physiology of the axis to understand its pathophysiology and reach an accurate diagnosis of its disorders.

The Brussels Collaboration on Bodily Integrity. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Clinical utility of early rapid genome sequencing in the evaluation of patients with differences of sex development

Establishing an early and accurate genetic diagnosis among patients with differences of sex development (DSD) is crucial in guiding the complex medical and psychosocial care they require. Genetic testing routinely utilized in clinical practice for this population is predicated upon physical exam findings and biochemical and endocrine profiling. This approach, however, is inefficient and unstandardized. Many patients with DSD, particularly those with 46,XY DSD, never receive a molecular genetic diagnosis. Rapid genome sequencing (rGS) is gaining momentum as a first-tier diagnostic instrument in the evaluation of patients with DSD given its ability to provide greater diagnostic yield and timely results. We present the case of a patient with nonbinary genitalia and systemic findings for whom rGS identified a novel variant of the WT1 gene and resulted in a molecular diagnosis within two weeks of life. This timeframe of diagnosis for syndromic DSD is largely unprecedented at our institution. Rapid GS expedited mobilization of a multidisciplinary medical team; enabled early understanding of clinical trajectory; informed planning of medical and surgical interventions; and guided individualized psychosocial support provided to the family. This case highlights the potential of early rGS in transforming the evaluation and care of patients with DSD.

World Athletics regulations unfairly affect female athletes with differences in sex development

World Athletics have introduced regulations preventing female athletes with certain differences in sex development from competing in the female category. We argue these regulations are not justified and should be removed. Firstly, we examine the reasoning and evidence underlying the position that these athletes have a substantial mean difference in performance from other female athletes such that it constitutes an advantage, and argue it is not sufficient. Secondly, if an advantage does exist, it needs to be demonstrated it is unfair. We argue the advantage would not be unfair because to say otherwise relies on a presupposition about whether these athletes are female, which involves contradictory and inconsistent definitions of sex. Thirdly, we contend that even if it is established that there is an advantage and it is unfair, the response of requiring athletes to take testosterone-suppressing medication is not appropriate and is unfair.

Individuals with numerical and structural variations of sex chromosomes: interdisciplinary management with focus on fertility potential

Diagnosis and management of individuals who have differences of sex development (DSD) due to numerical or structural variations of sex chromosomes (NSVSC) remains challenging. Girls who have Turner syndrome (45X) may present with varying phenotypic features, from classical/severe to minor, and some remain undiagnosed. Boys and girls who have 45,X/46,XY chromosomal mosaicism may have Turner syndrome-like features and short stature; therefore, unexplained short stature during childhood requires karyotype analysis in both sexes, particularly if characteristic features or atypical genitalia are present. Many individuals with Klinefelter syndrome (47XXY) remain undiagnosed or are only diagnosed as adults due to fertility problems. Newborn screening by heel prick tests could potentially identify sex chromosome variations but would have ethical and financial implications, and in-depth cost-benefit analyses are needed before nationwide screening can be introduced. Most individuals who have NSVSC have lifelong co-morbidities and healthcare should be holistic, personalized and centralized, with a focus on information, psychosocial support and shared decision-making. Fertility potential should be assessed individually and discussed at an appropriate age. Oocyte or ovarian tissue cryopreservation is possible in some women who have Turner syndrome and live births have been reported following assisted reproductive technology (ART). Testicular sperm cell extraction (TESE) is possible in some men who have 45,X/46,XY mosaicism, but there is no established protocol and no reported fathering of children. Some men with Klinefelter syndrome can now father a child following TESE and ART, with multiple reports of healthy live births. Children who have NSVSC, their parents and DSD team members need to address possibilities and ethical questions relating to potential fertility preservation, with guidelines and international studies still needed.

Babies born with ambiguous genitalia: Developing an educational resource for Australian midwives

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.