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Holmes L, Watts-Overall TM, Slettevold E, Gruia DC, Raines J, Rieger G. Sexual Orientation, Sexual Arousal, and Finger Length Ratios in Women. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:3419-3432. [PMID: 34297214 PMCID: PMC8604855 DOI: 10.1007/s10508-021-02095-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 06/13/2023]
Abstract
In general, women show physiological sexual arousal to both sexes. However, compared with heterosexual women, homosexual women are more aroused to their preferred sex, a pattern typically found in men. We hypothesized that homosexual women's male-typical arousal is due to their sex-atypical masculinization during prenatal development. We measured the sexual responses of 199 women (including 67 homosexual women) via their genital arousal and pupil dilation to female and male sexual stimuli. Our main marker of masculinization was the ratio of the index to ring finger, which we expected to be lower (a masculine pattern) in homosexual women due to increased levels of prenatal androgens. We further measured observer- and self-ratings of psychological masculinity-femininity as possible proxies of prenatal androgenization. Homosexual women responded more strongly to female stimuli than male stimuli and therefore had more male-typical sexual responses than heterosexual women. However, they did not have more male-typical digit ratios, even though this difference became stronger if analyses were restricted to white participants. Still, variation in women's digit ratios did not account for the link between their sexual orientation and their male-typical sexual responses. Furthermore, homosexual women reported and displayed more masculinity than heterosexual women, but their masculinity was not associated with their male-typical sexual arousal. Thus, women's sexual and behavioral traits, and potential anatomical traits, are possibly masculinized at different stages of gestation.
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Affiliation(s)
- Luke Holmes
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK.
| | - Tuesday M Watts-Overall
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK
- School of Psychology, University of East London, London, UK
| | - Erlend Slettevold
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK
- Department of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Dragos C Gruia
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK
| | - Jamie Raines
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK
| | - Gerulf Rieger
- Department of Psychology, University of Essex, Colchester, CO4 3SQ, UK
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2
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Control of testes mass by androgen receptor paralogs in a cichlid. J Comp Physiol B 2021; 192:107-114. [PMID: 34643776 DOI: 10.1007/s00360-021-01417-2] [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: 05/07/2021] [Revised: 09/17/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
Steroid hormones play numerous important and diverse roles in the differentiation and development of vertebrate primary and secondary reproductive characteristics. However, the exact role of androgen receptors-which bind circulating androgens-in this regulatory pathway is unclear. Teleost fishes further complicate this question by having two paralogs of the androgen receptor (ARα and ARβ) resulting from a duplication of their ancestral genome. We investigated the functional role of these two ARs on adult testes mass, by eliminating receptor function of one or both paralogs using CRISPR/Cas9 genome edited Astatotilapia burtoni, an African cichlid fish. Fish with two or more functional AR alleles were more likely to be male compared to fish with one or fewer, suggesting that the two paralogs may play redundant roles in the A. burtoni sex determination system. We replicated previous work showing that fish lacking functional ARβ possess testes smaller than wild-type fish, while fish lacking ARα possess testes larger than wild-type fish. However, we found novel evidence supporting a complex relationship between the two AR paralogs in the regulation of testes mass. For instance, the effects of ARα mutation on testes mass are eliminated in homozygous ARβ mutants but the reverse is not true. These results suggest a dynamic relationship between these two AR paralogs where ARβ functions may be permissive to ARα functions in the control of testes mass. This mechanism may contribute to the robust physiological plasticity displayed by A. burtoni and other social teleost fishes.
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Kuczyński W, Wibowo E, Hoshino T, Kudrycka A, Małolepsza A, Karwowska U, Pruszkowska M, Wasiak J, Kuczyńska A, Spałka J, Pruszkowska-Przybylska P, Mokros Ł, Białas A, Białasiewicz P, Sasanabe R, Blagrove M, Manning J. Understanding the Associations of Prenatal Androgen Exposure on Sleep Physiology, Circadian Proteins, Anthropometric Parameters, Hormonal Factors, Quality of Life, and Sex Among Healthy Young Adults: Protocol for an International, Multicenter Study. JMIR Res Protoc 2021; 10:e29199. [PMID: 34612837 PMCID: PMC8529469 DOI: 10.2196/29199] [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: 03/29/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background The ratio of the second finger length to the fourth finger length (2D:4D ratio) is considered to be negatively correlated with prenatal androgen exposure (PAE) and positively correlated with prenatal estrogen. Coincidentally, various brain regions are sensitive to PAE, and their functions in adults may be influenced by the prenatal actions of sex hormones. Objective This study aims to assess the relationship between PAE (indicated by the 2D:4D ratio) and various physiological (sex hormone levels and sleep-wake parameters), psychological (mental health), and sexual parameters in healthy young adults. Methods This study consists of two phases. In phase 1, we will conduct a survey-based study and anthropometric assessments (including 2D:4D ratio and BMI) in healthy young adults. Using validated questionnaires, we will collect self-reported data on sleep quality, sexual function, sleep chronotype, anxiety, and depressive symptoms. In phase 2, a subsample of phase 1 will undergo polysomnography and physiological and genetic assessments. Sleep architecture data will be obtained using portable polysomnography. The levels of testosterone, estradiol, progesterone, luteinizing hormone, follicle-stimulating hormone, prolactin, melatonin, and circadian regulatory proteins (circadian locomotor output cycles kaput [CLOCK], timeless [TIM], and period [PER]) and the expression levels of some miRNAs will be measured using blood samples. The rest and activity cycle will be monitored using actigraphy for a 7-day period. Results In Poland, 720 participants were recruited for phase 1. Among these, 140 completed anthropometric measurements. In addition, 25 participants joined and completed phase 2 data collection. Recruitment from other sites will follow. Conclusions Findings from our study may help to better understand the plausible role of PAE in sleep physiology, mental health, and sexual quality of life in young adults. International Registered Report Identifier (IRRID) DERR1-10.2196/29199
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Affiliation(s)
- Wojciech Kuczyński
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Erik Wibowo
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Tetsuro Hoshino
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University, Aichi, Japan
| | - Aleksandra Kudrycka
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Małolepsza
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Urszula Karwowska
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Milena Pruszkowska
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Jakub Wasiak
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Kuczyńska
- Department of Microbiology and Laboratory Medical Immunology, Medical University of Lodz, Lodz, Poland
| | - Jakub Spałka
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | | | - Łukasz Mokros
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Adam Białas
- Department of Pathobiology of Respiratory Diseases, Medical University of Lodz, Lodz, Poland
| | - Piotr Białasiewicz
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
| | - Ryujiro Sasanabe
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University, Aichi, Japan
| | - Mark Blagrove
- Department of Psychology, Swansea University, Swansea, United Kingdom
| | - John Manning
- Applied Sports, Technology, Exercise, and Medicine Research Centre, Swansea University, Swansea, United Kingdom
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Manzato E, Gualandi M, Roncarati E. Complete androgen insensitivity syndrome (CAIS) and eating disorders: a case report. Eat Weight Disord 2021; 26:2421-2426. [PMID: 33201394 DOI: 10.1007/s40519-020-01069-1] [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: 08/25/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022] Open
Abstract
Androgen Insensitivity Syndrome represents a disorder due to partial (PAIS), mild (MAIS) or complete (CAIS) resistance to androgens caused by X-linked mutations of androgen receptor gene. CAIS is characterized by a female phenotype and XY karyotype. Cases of patients with CAIS and associated obesity have been reported, while to date, there are no reports about the onset of an Eating Disorder (ED) in the carriers of this condition. We describe the case of a patient affected by CAIS and Anorexia Nervosa (AN) restricting type later shifted to Bulimia Nervosa (BN). A previous overweight was present since childhood, contributing to severe Body Dissatisfaction (BD) and consequent restrictive behaviour in adolescence. Beyond its peculiarity, this case highlights also the importance of diagnosing and monitoring the overweight and BD in CAIS patients to avoid the onset of an ED.Level of Evidence: V, descriptive study.
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Affiliation(s)
- E Manzato
- Psychiatrist, Former University of Ferrara and Former Chief of Eating and Weight Disorders Center, University Hospital S. Anna, chief of Eating and Weight Disorders Unit"L'Albero", Private Hospital "Salus", Via Arianuova 38, Ferrara, Italy.
| | - M Gualandi
- Medical Doctor, Former Responsible of Day Hospital of Internal Medicine and Eating Disorders, University Hospital S. Anna, Ferrara, Italy
| | - E Roncarati
- Dietitian, University of Ferrara, Dietitian of Eating and Weight Disorders "L'Albero", Private Hospital "Salus", Ferrara, Italy
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5
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Barros BA, de Oliveira LR, Surur CRC, Barros-Filho ADA, Maciel-Guerra AT, Guerra-Junior G. Complete androgen insensitivity syndrome and risk of gonadal malignancy: systematic review. Ann Pediatr Endocrinol Metab 2021; 26:19-23. [PMID: 33819955 PMCID: PMC8026333 DOI: 10.6065/apem.2040170.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/13/2020] [Indexed: 12/02/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS) is a rare condition characterized by 46,XY karyotype, female external genitalia, absence of uterus, and testes located intra-abdominally, in the inguinal ring or in the labia majora. In the present study, the frequency of testicular malignancy in prepubertal and pubertal patients with CAIS who underwent gonadectomy or gonadal biopsy were evaluated. Systematic review was performed using electronic databases according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. The samples included 15 articles published between 1998 and 2019. From a total of 456 patients who underwent gonadectomy or gonadal biopsy, 6.14% had a premalignant lesion and most were postpubertal (82.14%). A malignant lesion was found in 1.3% and all were postpubertal. Because the risk of malignancy is very low in prepubertal patients with CAIS, gonadectomy may be delayed until puberty is complete, allowing it to progress naturally; however, close follow-up of the patient is required.
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Affiliation(s)
- Beatriz Amstalden Barros
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Pediatrics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Address for correspondence: Beatriz Amstalden Barros Rua Tessalia Vieira de Camargo, 126 Cidade Universitaria, Campinas (SP) 13083-887, Brazil
| | | | | | | | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Medical Genetics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Pediatrics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil
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6
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A Management Protocol for Gonad Preservation in Patients with Androgen Insensitivity Syndrome. J Pediatr Adolesc Gynecol 2019; 32:605-611. [PMID: 31233832 PMCID: PMC6917890 DOI: 10.1016/j.jpag.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Historically, individuals with androgen insensitivity syndrome (AIS) were managed with removal of gonadal tissue at various ages to avert the risk of gonadal malignancy. Recently, clinical practice changed, with gonadectomy being postponed until late adolescence. Adolescents and adults with complete AIS have questioned this approach. Additionally, testicular germ cell tumors are increasingly believed to be quite rare with rates as low as 0% in molecularly confirmed individuals with AIS. Gonadectomy deprives patients of the benefits of their endogenous hormones and potential fertility. Furthermore, human rights organizations advocate for deferring irreversible surgery in conditions known as differences of sex development, which includes AIS, to allow patient autonomy in decision-making. Recent literature supports an approach that uses risk stratification to manage gonads in AIS. Herein we review what is known about malignancy risk in the different subtypes of AIS and propose a management protocol for gonad retention.
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Davies K. The XY Female: Exploring Care for Adolescent Girls with Complete Androgen Insensitivity Syndrome. Compr Child Adolesc Nurs 2019; 43:378-388. [DOI: 10.1080/24694193.2019.1691677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kate Davies
- Department of Advanced and Integrated Practice, London South Bank University, London, UK
- Queen Mary University of London/Barts and the London School of Medicine, London, UK
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8
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Roselli CE. Neurobiology of gender identity and sexual orientation. J Neuroendocrinol 2018; 30:e12562. [PMID: 29211317 PMCID: PMC6677266 DOI: 10.1111/jne.12562] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/03/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
Sexual identity and sexual orientation are independent components of a person's sexual identity. These dimensions are most often in harmony with each other and with an individual's genital sex, although not always. The present review discusses the relationship of sexual identity and sexual orientation to prenatal factors that act to shape the development of the brain and the expression of sexual behaviours in animals and humans. One major influence discussed relates to organisational effects that the early hormone environment exerts on both gender identity and sexual orientation. Evidence that gender identity and sexual orientation are masculinised by prenatal exposure to testosterone and feminised in it absence is drawn from basic research in animals, correlations of biometric indices of androgen exposure and studies of clinical conditions associated with disorders in sexual development. There are, however, important exceptions to this theory that have yet to be resolved. Family and twin studies indicate that genes play a role, although no specific candidate genes have been identified. Evidence that relates to the number of older brothers implicates maternal immune responses as a contributing factor for male sexual orientation. It remains speculative how these influences might relate to each other and interact with postnatal socialisation. Nonetheless, despite the many challenges to research in this area, existing empirical evidence makes it clear that there is a significant biological contribution to the development of an individual's sexual identity and sexual orientation.
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Affiliation(s)
- C E Roselli
- Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR, USA
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9
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Herbert J. Testosterone, Cortisol and Financial Risk-Taking. Front Behav Neurosci 2018; 12:101. [PMID: 29867399 PMCID: PMC5964298 DOI: 10.3389/fnbeh.2018.00101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/27/2018] [Indexed: 11/13/2022] Open
Abstract
Both testosterone and cortisol have major actions on financial decision-making closely related to their primary biological functions, reproductive success and response to stress, respectively. Financial risk-taking represents a particular example of strategic decisions made in the context of choice under conditions of uncertainty. Such decisions have multiple components, and this article considers how much we know of how either hormone affects risk-appetite, reward value, information processing and estimation of the costs and benefits of potential success or failure, both personal and social. It also considers how far we can map these actions on neural mechanisms underlying risk appetite and decision-making, with particular reference to areas of the brain concerned in either cognitive or emotional functions.
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Affiliation(s)
- Joe Herbert
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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10
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Forger NG, Ruszkowski E, Jacobs A, Wallen K. Effects of sex and prenatal androgen manipulations on Onuf's nucleus of rhesus macaques. Horm Behav 2018; 100:39-46. [PMID: 29510099 PMCID: PMC6084473 DOI: 10.1016/j.yhbeh.2018.03.003] [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: 12/19/2017] [Revised: 02/15/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
The role of gonadal steroids in sexual differentiation of the central nervous system (CNS) is well established in rodents, but no study to date has manipulated androgens prenatally and examined their effects on any CNS structure in a primate. Onuf's nucleus is a column of motoneurons in the sacral spinal cord that innervates the striated perineal muscles. This cell group is larger in males than in females of many species, due to androgens acting during a sensitive perinatal period. Here, we examined Onuf's nucleus in 21 adult rhesus monkeys, including control males and females, as well as males whose mothers had been treated with an anti-androgen or testosterone during gestation. We found a robust sex difference, with more motoneurons in control males than in females. The soma size of Onuf's nucleus motoneurons was also marginally larger in males. Treatment with the anti-androgen flutamide for 35-40 days during early gestation partially blocked masculinization of Onuf's nucleus: motoneuron number in flutamide-treated males was decreased relative to control and testosterone-treated males, but remained greater than in females, with no effect on cell size. A control motor nucleus that innervates foot muscles (Pes9) showed no difference in motoneuron number or size between control males and females. Prenatal testosterone treatment of males did not alter Onuf's nucleus motoneuron number, but did increase the size of both Onuf's and Pes9 motoneurons. Thus, prenatal androgen manipulations cause cellular-level changes in the primate CNS, which may underlie previously observed effects of these manipulations on behavior.
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Affiliation(s)
- Nancy G Forger
- Neuroscience Institute, Georgia State University, Atlanta, GA 30302, United States.
| | - Elara Ruszkowski
- Neuroscience Institute, Georgia State University, Atlanta, GA 30302, United States
| | - Andrew Jacobs
- Neuroscience Institute, Georgia State University, Atlanta, GA 30302, United States
| | - Kim Wallen
- Department of Psychology, Emory University, Atlanta, GA 30322, United States
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11
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Bramble MS, Lipson A, Vashist N, Vilain E. Effects of chromosomal sex and hormonal influences on shaping sex differences in brain and behavior: Lessons from cases of disorders of sex development. J Neurosci Res 2017; 95:65-74. [PMID: 27841933 DOI: 10.1002/jnr.23832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/30/2016] [Accepted: 06/20/2016] [Indexed: 01/15/2023]
Abstract
Sex differences in brain development and postnatal behavior are determined largely by genetic sex and in utero gonadal hormone secretions. In humans however, determining the weight that each of these factors contributes remains a challenge because social influences should also be considered. Cases of disorders of sex development (DSD) provide unique insight into how mutations in genes responsible for gonadal formation can perturb the subsequent developmental hormonal milieu and elicit changes in normal human brain maturation. Specific forms of DSDs such as complete androgen insensitivity syndrome (CAIS), congenital adrenal hyperplasia (CAH), and 5α-reductase deficiency syndrome have variable effects between males and females, and the developmental outcomes of such conditions are largely dependent on sex chromosome composition. Medical and psychological works focused on CAH, CAIS, and 5α-reductase deficiency have helped form the foundation for understanding the roles of genetic and hormonal factors necessary for guiding human brain development. Here we highlight how the three aforementioned DSDs contribute to brain and behavioral phenotypes that can uniquely affect 46,XY and 46,XX individuals in dramatically different fashions. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew S Bramble
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Allen Lipson
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Neerja Vashist
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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12
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Isaacson D, Shen J, Cao M, Sinclair A, Yue X, Cunha G, Baskin L. Renal Subcapsular xenografing of human fetal external genital tissue - A new model for investigating urethral development. Differentiation 2017; 98:1-13. [PMID: 29031189 DOI: 10.1016/j.diff.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/26/2017] [Accepted: 09/11/2017] [Indexed: 12/01/2022]
Abstract
In this paper, we introduce our novel renal subcapsular xenograft model for the study of human penile urethral and clitoral development. We grafted fifteen intact fetal penes and clitorides 8-11 weeks fetal age under the renal capsules of gonadectomized athymic mice. The mice were treated with a subcutaneous pellet of dihydrotestosterone (DHT), diethylstilbestrol (DES) or untreated with hormones. Xenografts were harvested after fourteen days of growth and analyzed via serial histologic sectioning and immunostaining for Ki-67, cytokeratins 6, 7 and 10, uroplakin and the androgen receptor. Non-grafted specimens of similar fetal age were sectioned and immunostained for the same antigenic markers. 14/15 (93.3%) grafts were successfully propagated and harvested. The developing urethral plate, urethral groove, tubular urethra, corporal bodies and preputial lamina were easily identifiable. These structures demonstrated robust cellularity, appropriate architecture and abundant Ki-67 expression. Expression patterns of cytokeratins 6, 7 and 10, uroplakin and the androgen receptor in xenografted specimens demonstrated characteristic male/female differences analogous to non-grafted specimens. DHT treatment reliably produced tubularization of nascent urethral and vestibular structures and male patterns of androgen receptor expression in grafts of both genetic sexes while estrogenic or hormonally absent conditions reliably resulted in a persistent open urethral/vestibular groove and female patterns of androgen receptor expression. This model's success enables further study into causal pathways by which endocrine-disrupting and endocrine-mimicking substances may directly cause disruption of normal human urethral development or hypospadias.
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Affiliation(s)
- Dylan Isaacson
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Joel Shen
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Mei Cao
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Adriane Sinclair
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Xuan Yue
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Gerald Cunha
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Laurence Baskin
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA.
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Controversies of Sex Re-assignment in Genetic Males with Congenital Inadequacy of the Penis. Indian J Pediatr 2017; 84:700-708. [PMID: 28687949 DOI: 10.1007/s12098-017-2412-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
Abstract
Sex assignment in 46XY genetic male children with congenital inadequacy of the penis (CIP) is controversial. Traditionally, children with penile length less than 2 cm at birth are considered unsuitable to be raised as males. They are typically re-assigned to female-sex and feminizing genitoplasty is usually done in infancy. However, the concept of cerebral androgen imprinting has caused paradigm shift in the philosophy of sex re-assignment. Masculinization of the brain, rather than length of the penis, is the modern criterion of sex re-assignment in CIP. This review summarizes the current understanding of the complex issue. In 46XY children with CIP, male-sex assignment appears appropriate in non-hormonal conditions such as idiopathic micropenis, aphallia and exstrophy. Female-sex re-assignment appears acceptable in complete androgen insensitivity (CAIS), while partial androgen insensitivity syndrome (PAIS) patients are highly dissatisfied with the assignment of either sex. Children with 5-alpha reductase deficiency are likely to have spontaneous penile lengthening at puberty. Hence, they are better raised as males. Although female assignment is common in pure gonadal dysgenesis, long-term results are not known to justify the decision.
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Raveenthiran V. Neonatal Sex Assignment in Disorders of Sex Development: A Philosophical Introspection. J Neonatal Surg 2017; 6:58. [PMID: 28920018 PMCID: PMC5593477 DOI: 10.21699/jns.v6i3.604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 06/11/2017] [Indexed: 11/11/2022] Open
Abstract
Management of ambiguous genitalia is highly controversial. This condition was known previously as intersex and presently as disorders of sex development (DSD). There is no consensus regarding the choice, timing and method of sex assignment in neonates with DSD. Consensus conferences could not unify the views of various stakeholders and third parties. This article philosophically examines the nature and origin of such controversies. Misconception, bias and conflicting priorities are identified as the three cardinal sources of controversies. Conceptual duality of sexes, confused notion of sex and gender, bias towards penetrative intercourse, conflict between utopian ideals and reality, unwillingness to compromise are identified as perpetuators of controversies. Suggestions are made regarding sex assignment in various types of DSD based on the understanding of published literature and the author's personal experience.
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Affiliation(s)
- V Raveenthiran
- Department of Pediatric Surgery, Sri Ramasamy Memorial (SRM) Medical College SRM University, Chennai, India
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Reed BG, Bou Nemer L, Carr BR. Has testosterone passed the test in premenopausal women with low libido? A systematic review. Int J Womens Health 2016; 8:599-607. [PMID: 27785108 PMCID: PMC5066846 DOI: 10.2147/ijwh.s116212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background There are limited evaluation and treatment options for low libido in premenopausal women. This review sought to evaluate the available evidence supporting the evaluation of testosterone serum levels and testosterone treatment of premenopausal women with low libido. Methods MEDLINE, PubMed, and ClinicalTrials.gov were searched for articles that referenced the evaluation of testosterone serum level and/or testosterone treatment on premenopausal women with low libido from 1995 to 2015. Additional references were obtained from the reference sections of other papers and from peer review. Studies that included only postmenopausal women were excluded. A total of 13 studies were reviewed in detail. Nine studies examined the relationship between testosterone serum levels and sexuality, an additional three studies examined the effect of testosterone treatment on premenopausal women with low libido, and one study examined both the topics. Results Six of the ten testosterone serum evaluation studies failed to show a significant association between testosterone serum level and libido. Only one out of four studies examining testosterone treatment in premenopausal women was able to show any clear improvement in libido; however, the effect was limited to only the intermediate dose of testosterone, with the low and high doses of testosterone not producing any effect. Conclusion The currently available evidence does not support testosterone serum evaluation or treatment in premenopausal women with low libido. Hence, further studies are warranted.
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Affiliation(s)
- Beverly G Reed
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology & Infertility, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laurice Bou Nemer
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology & Infertility, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bruce R Carr
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology & Infertility, University of Texas Southwestern Medical Center, Dallas, TX, USA
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16
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Hines M, Constantinescu M, Spencer D. Early androgen exposure and human gender development. Biol Sex Differ 2015; 6:3. [PMID: 25745554 PMCID: PMC4350266 DOI: 10.1186/s13293-015-0022-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/05/2015] [Indexed: 02/01/2023] Open
Abstract
During early development, testosterone plays an important role in sexual differentiation of the mammalian brain and has enduring influences on behavior. Testosterone exerts these influences at times when the testes are active, as evidenced by higher concentrations of testosterone in developing male than in developing female animals. This article critically reviews the available evidence regarding influences of testosterone on human gender-related development. In humans, testosterone is elevated in males from about weeks 8 to 24 of gestation and then again during early postnatal development. Individuals exposed to atypical concentrations of testosterone or other androgenic hormones prenatally, for example, because of genetic conditions or because their mothers were prescribed hormones during pregnancy, have been consistently found to show increased male-typical juvenile play behavior, alterations in sexual orientation and gender identity (the sense of self as male or female), and increased tendencies to engage in physically aggressive behavior. Studies of other behavioral outcomes following dramatic androgen abnormality prenatally are either too small in their numbers or too inconsistent in their results, to provide similarly conclusive evidence. Studies relating normal variability in testosterone prenatally to subsequent gender-related behavior have produced largely inconsistent results or have yet to be independently replicated. For studies of prenatal exposures in typically developing individuals, testosterone has been measured in single samples of maternal blood or amniotic fluid. These techniques may not be sufficiently powerful to consistently detect influences of testosterone on behavior, particularly in the relatively small samples that have generally been studied. The postnatal surge in testosterone in male infants, sometimes called mini-puberty, may provide a more accessible opportunity for measuring early androgen exposure during typical development. This approach has recently begun to be used, with some promising results relating testosterone during the first few months of postnatal life to later gender-typical play behavior. In replicating and extending these findings, it may be important to assess testosterone when it is maximal (months 1 to 2 postnatal) and to take advantage of the increased reliability afforded by repeated sampling.
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Affiliation(s)
- Melissa Hines
- Department of Psychology, University of Cambridge, Cambridge, UK
| | | | - Debra Spencer
- Department of Psychology, University of Cambridge, Cambridge, UK
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17
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Berm�dez de la Vega JA, Fern�ndez-Cancio M, Bernal S, Aud� L. Complete Androgen Insensitivity Syndrome Associated with Male Gender Identity or Female Precocious Puberty in the Same Family. Sex Dev 2015; 9:75-9. [DOI: 10.1159/000371617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/19/2022] Open
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Doehnert U, Bertelloni S, Werner R, Dati E, Hiort O. Characteristic features of reproductive hormone profiles in late adolescent and adult females with complete androgen insensitivity syndrome. Sex Dev 2015; 9:69-74. [PMID: 25613104 DOI: 10.1159/000371464] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 11/19/2022] Open
Abstract
Little is known about gonadotropins and sex steroid levels in postpubertal women with complete androgen insensitivity syndrome (CAIS). In order to define reproductive hormone profiles in women with CAIS and intact gonads, 42 postpubertal females with proven CAIS (age range 14-50 years) with testes in situ were examined. Reproductive hormone values [testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicle-stimulating hormone (FSH)] were assessed by commercially available immunoassays. In women with CAIS, LH levels (median 18.5 IU/l, range 5.5-51.1 IU/l) were elevated above the usual adult reference ranges, whereas FSH values (3.5 IU/l, 0.4-16.3 IU/l) were not. Basal T (20 nmol/l, 6-52 nmol/l) and E2 values (113 pmol/l; 18-257 pmol/l) were found in the usual adult male reference ranges; SHBG levels (53 nmol/l, 15-180 nmol/l) were in the adult female reference range. Calculated free androgen indices (Tx10³/SHBG: 380, 114-863) and aromatization indices (E2/T: 0.052, 0.020-0.196) did not differ from the reference ranges for adult men given in the literature (Tx10³/SHBG: 315-936; E2/T: 0.03-0.07). Reproductive hormone profiles in women with CAIS do not follow the usual male/female pattern, suggesting a specific postpubertal hormone milieu. Albeit calculation of CAIS-specific reference ranges requires larger series and standardization of laboratory methods, these results may be a prerequisite for the identification of pathologic hormone patterns in women with CAIS and gonads in situ. The present data will also be useful to monitor hormone replacement therapy in individuals with removed gonads.
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Affiliation(s)
- Ulla Doehnert
- Division of Experimental Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
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19
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Wisniewski AB, Espinoza-Varas B, Aston CE, Edmundson S, Champlin CA, Pasanen EG, McFadden D. Otoacoustic emissions, auditory evoked potentials and self-reported gender in people affected by disorders of sex development (DSD). Horm Behav 2014; 66:467-74. [PMID: 25038289 PMCID: PMC4163528 DOI: 10.1016/j.yhbeh.2014.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 11/17/2022]
Abstract
Both otoacoustic emissions (OAEs) and auditory evoked potentials (AEPs) are sexually dimorphic, and both are believed to be influenced by prenatal androgen exposure. OAEs and AEPs were collected from people affected by 1 of 3 categories of disorders of sex development (DSD) - (1) women with complete androgen insensitivity syndrome (CAIS); (2) women with congenital adrenal hyperplasia (CAH); and (3) individuals with 46,XY DSD including prenatal androgen exposure who developed a male gender despite initial rearing as females (men with DSD). Gender identity (GI) and role (GR) were measured both retrospectively and at the time of study participation, using standardized questionnaires. The main objective of this study was to determine if patterns of OAEs and AEPs correlate with gender in people affected by DSD and in controls. A second objective was to assess if OAE and AEP patterns differed according to degrees of prenatal androgen exposure across groups. Control males, men with DSD, and women with CAH produced fewer spontaneous OAEs (SOAEs) - the male-typical pattern - than control females and women with CAIS. Additionally, the number of SOAEs produced correlated with gender development across all groups tested. Although some sex differences in AEPs were observed between control males and females, AEP measures did not correlate with gender development, nor did they vary according to degrees of prenatal androgen exposure, among people with DSD. Thus, OAEs, but not AEPs, may prove useful as bioassays for assessing early brain exposure to androgens and predicting gender development in people with DSD.
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Affiliation(s)
- Amy B Wisniewski
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Blas Espinoza-Varas
- Department of Communication Sciences and Disorders, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126, USA.
| | - Christopher E Aston
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Shelagh Edmundson
- Department of Communication Sciences and Disorders, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126, USA.
| | - Craig A Champlin
- Department of Communication Sciences and Disorders, University of Texas at Austin, TX 78712, USA.
| | - Edward G Pasanen
- Department of Psychology and Center for Perceptual Systems, University of Texas at Austin, TX 78712, USA.
| | - Dennis McFadden
- Department of Psychology and Center for Perceptual Systems, University of Texas at Austin, TX 78712, USA.
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Meshkat B, Matcovici M, Buckley C, Salama M, Perthiani HK. Diagnostic laparoscopy in a twelve year old girl with right iliac fossa pain: A life changing diagnosis of complete androgen insensitivity syndrome. Int J Surg Case Rep 2014; 5:505-8. [PMID: 24995665 PMCID: PMC4147648 DOI: 10.1016/j.ijscr.2014.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/04/2014] [Accepted: 03/10/2014] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Right iliac fossa (RIF) pain is one of the most common presenting complaints faced by general surgeons in the emergency department. Correct diagnosis and appropriate surgical intervention can often pose a challenge. PRESENTATION OF CASE A 12-year-old girl presented to the emergency department with a four day history of initially central acute abdominal pain, now localised in the RIF. During laparoscopy, the following findings were made: macroscopically dilated appendix, right and left gonads at the internal opening of the inguinal canal, empty pelvis with a rudimentary uterus on the right side. No evidence of fallopian tubes or connection of uterus to the vagina and broad based, non-inflamed Meckel's diverticulum. An incidental diagnosis of complete androgen insensitivity syndrome was made. DISCUSSION Androgen insensitivity syndrome (AIS) is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. CONCLUSION This case report highlights the advantage of laparoscopy as a diagnostic and treatment tool in a twelve year old girl with multiple intra-abdominal findings. While the ultimate diagnosis responsible for her symptom of RIF pain was acute appendicitis, the additional diagnosis of CAIS and incidental Meckel's would have otherwise likely gone undetected.
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Affiliation(s)
- Babak Meshkat
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland.
| | - Melania Matcovici
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Claire Buckley
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Muhammad Salama
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
| | - Haresh K Perthiani
- Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, County Louth, Ireland
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21
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A large seminoma occurring 20 years after diagnosis of complete androgen insensitivity syndrome: A case report. GYNECOLOGIC ONCOLOGY CASE REPORTS 2013; 5:16-8. [PMID: 24371685 PMCID: PMC3862327 DOI: 10.1016/j.gynor.2013.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 02/27/2013] [Indexed: 11/22/2022]
Abstract
•A seminoma developed in a patient with androgen insensitivity syndrome.•The patient had a de novo androgen receptor mutation.•Proper management of AIS, including appropriate genetic counseling, is necessary.
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22
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El-Sherbiny M. Disorders of sexual differentiation: II. Diagnosis and treatment. Arab J Urol 2013; 11:27-32. [PMID: 26579241 PMCID: PMC4442922 DOI: 10.1016/j.aju.2012.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 11/03/2012] [Accepted: 11/08/2012] [Indexed: 11/27/2022] Open
Abstract
Objectives To provide a review and summary of recent advances in the diagnosis and management of disorder(s) of sexual differentiation (DSD), an area that has developed over recent years with implications for the management of children with DSD; and to assess the refinements in the surgical techniques used for genital reconstruction. Methods Recent publications (in the previous 10 years) were identified using PubMed, as were relevant previous studies, using following keywords; ‘diagnosis and management’, ‘ambiguous genitalia’, ‘intersex’, ‘disorders of sexual differentiation’, ‘genitogram’, ‘endocrine assessment’, ‘gender assignment’, ‘genitoplasty’, and ‘urogenital sinus’. The findings were reviewed. Results Arbitrary criteria have been developed to select patients likely to have DSD. Unnecessary tests, especially those that require anaesthesia or are associated with radiation exposure, should be limited to situations where a specific question needs to be answered. Laparoscopy is an important diagnostic tool in selected patients. The routine use of multidisciplinary diagnostic and expert surgical teams has become standard. Full disclosure of different therapeutic approaches and their timing is recommended. Conclusions Diagnostic tests should be tailored according to the available information. Parents and/or patients should be made aware of the paucity of well-designed studies, as these conditions are rare. Unnecessary irreversible surgery should be postponed until a multidisciplinary experienced team, with the parents’ and or patients’ approval, can make a well-judged decision.
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23
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Ercan O, Kutlug S, Uysal O, Alikasifoglu M, Inceoglu D. Gender Identity and Gender Role in DSD Patients Raised as Females: A Preliminary Outcome Study. Front Endocrinol (Lausanne) 2013; 4:86. [PMID: 23874323 PMCID: PMC3711069 DOI: 10.3389/fendo.2013.00086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/29/2013] [Indexed: 12/31/2022] Open
Abstract
Gender identity and gender role are expected to be consistent with gender assignment for optimal DSD management outcome. To our knowledge, our study is the first to attempt evaluation of gender related outcomes in Turkish DSD patients. After receiving institutional ethical board approval and subject (or parent) informed consent, subjects with DSD raised as girls (22 patients 46 XX DSD, 11 patients 46 XY DSD) answered 566 questions of the Minnesota Multiphasic Personality Inventory (MMPI) questionnaire including 60-item Masculinity-Femininity (MF) subscale which was the focus in this study. Controls (n: 50) were females similar to the probands in age, level of education, relationship status, and having a job or not also answered all questions. The answers were evaluated by a trained psychologist (Derya Inceoglu) on MMPI. For statistical purposes, seven findings were obtained from the data related to the MF subscale from the patients and controls. Of these seven findings (S1-S7), two were associated with masculinity (S3-S4) and another two were associated with femininity (S5-S6). In DSD patients, the percentages of masculinity findings were significantly higher when compared to controls (p < 0.001 and p < 0.001 for S3 and S4, respectively). In controls, the percentages of femininity findings were significantly higher when compared to DSD females (p < 0.001 and p < 0.001 for S5 and S6 respectively). There was no significant difference between 46 XX DSD patients and 46 XY DSD patients with respect to the percentage of any of the seven findings. Two patients requested gender change to male; only these two patients had the finding stating that sexual impulses could come to existence as actions (S7). In conclusion efforts to identify modifiable factors with negative impact and thus modifying them, and professional guidance may be important in minimizing the encountered gender related problems in DSD patients.
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Affiliation(s)
- Oya Ercan
- Pediatric Endocrinology and Adolescent Divisions, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
- *Correspondence: Oya Ercan, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Fatih 34303, Istanbul, Turkey e-mail:
| | - Seyhan Kutlug
- Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Omer Uysal
- Department of Biostatistics and Medical Informatics, School of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Mujgan Alikasifoglu
- Adolescent Division, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Derya Inceoglu
- Academic Success Monitoring and Counseling Program, Center for Individual and Academic Development-CIAD, Sabanci University, Istanbul, Turkey
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Abstract
Disorders of sex development (DSDs) are estimated to be prevalent in 0.1-2% of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation-processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5-20% of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63%). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.
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25
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Abstract
Many people believe that sexual orientation (homosexuality vs. heterosexuality) is determined by education and social constraints. There are, however, a large number of studies indicating that prenatal factors have an important influence on this critical feature of human sexuality. Sexual orientation is a sexually differentiated trait (over 90% of men are attracted to women and vice versa). In animals and men, many sexually differentiated characteristics are organized during early life by sex steroids, and one can wonder whether the same mechanism also affects human sexual orientation. Two types of evidence support this notion. First, multiple sexually differentiated behavioral, physiological, or even morphological traits are significantly different in homosexual and heterosexual populations. Because some of these traits are known to be organized by prenatal steroids, including testosterone, these differences suggest that homosexual subjects were, on average, exposed to atypical endocrine conditions during development. Second, clinical conditions associated with significant endocrine changes during embryonic life often result in an increased incidence of homosexuality. It seems therefore that the prenatal endocrine environment has a significant influence on human sexual orientation but a large fraction of the variance in this behavioral characteristic remains unexplained to date. Genetic differences affecting behavior either in a direct manner or by changing embryonic hormone secretion or action may also be involved. How these biological prenatal factors interact with postnatal social factors to determine life-long sexual orientation remains to be determined.
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Affiliation(s)
- Jacques Balthazart
- University of Liège, Groupe Interdisciplinaire de Génoprotéomique Appliquée Neurosciences, Research Group in Behavioral Neuroendocrinology, 1 Avenue de l'Hôpital (B36), B-4000 Liège, Belgium.
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26
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Hines M. Prenatal endocrine influences on sexual orientation and on sexually differentiated childhood behavior. Front Neuroendocrinol 2011; 32:170-82. [PMID: 21333673 PMCID: PMC3296090 DOI: 10.1016/j.yfrne.2011.02.006] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 02/04/2011] [Accepted: 02/14/2011] [Indexed: 11/27/2022]
Abstract
Both sexual orientation and sex-typical childhood behaviors, such as toy, playmate and activity preferences, show substantial sex differences, as well as substantial variability within each sex. In other species, behaviors that show sex differences are typically influenced by exposure to gonadal steroids, particularly testosterone and its metabolites, during early development (prenatally or neonatally). This article reviews the evidence regarding prenatal influences of gonadal steroids on human sexual orientation, as well as sex-typed childhood behaviors that predict subsequent sexual orientation. The evidence supports a role for prenatal testosterone exposure in the development of sex-typed interests in childhood, as well as in sexual orientation in later life, at least for some individuals. It appears, however, that other factors, in addition to hormones, play an important role in determining sexual orientation. These factors have not been well-characterized, but possibilities include direct genetic effects, and effects of maternal factors during pregnancy. Although a role for hormones during early development has been established, it also appears that there may be multiple pathways to a given sexual orientation outcome and some of these pathways may not involve hormones.
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Affiliation(s)
- Melissa Hines
- Department of Social and Developmental Psychology, University of Cambridge, UK.
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27
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Krege S. [Obvious aspects of the external genitalia in disorders of sexual differentiation]. Urologe A 2010; 49:1490-5. [PMID: 21110185 DOI: 10.1007/s00120-010-2405-6] [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: 11/27/2022]
Abstract
Birth of a child with intersexual external genitalia poses a severe psychological burden for the parents. Therefore, it is of utmost importance to find the correct diagnosis quickly. Inspection of the genitalia might already give important hints. Serological and molecular genetic examinations can verify the diagnosis in the majority of cases. Chromosomal analysis is obligatory.To understand the different appearances of intersexual genitalia, first the normal embryological sexual differentiation is explained in the article. Then the aspects of virilized genitalia in cases of a chromosomal 46,XX child and of female appearing genitalia in cases of a chromosomal 46,XY child are described. Differences are analysed. Besides mentioning the main causes of disorders in sexual differentiation a brief summary of diagnostics and therapeutic considerations is given.
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Affiliation(s)
- S Krege
- Klinik für Urologie und Kinderurologie, Alexianer Krankenhaus Maria-Hilf GmbH, Dießemerbruch 81, 47805, Krefeld, Deutschland.
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Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:919707. [PMID: 20981291 PMCID: PMC2963131 DOI: 10.1155/2010/919707] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 08/04/2010] [Accepted: 08/09/2010] [Indexed: 12/01/2022]
Abstract
The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.
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Longitudinally mapping the influence of sex and androgen signaling on the dynamics of human cortical maturation in adolescence. Proc Natl Acad Sci U S A 2010; 107:16988-93. [PMID: 20841422 DOI: 10.1073/pnas.1006025107] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Humans have systematic sex differences in brain-related behavior, cognition, and pattern of mental illness risk. Many of these differences emerge during adolescence, a developmental period of intense neurostructural and endocrine change. Here, by creating "movies" of sexually dimorphic brain development using longitudinal in vivo structural neuroimaging, we show regionally specific sex differences in development of the cerebral cortex during adolescence. Within cortical subsystems known to underpin domains of cognitive behavioral sex difference, structural change is faster in the sex that tends to perform less well within the domain in question. By stratifying participants through molecular analysis of the androgen receptor gene, we show that possession of an allele conferring more efficient functioning of this sex steroid receptor is associated with "masculinization" of adolescent cortical maturation. Our findings extend models first established in rodents, and suggest that in humans too, sex and sex steroids shape brain development in a spatiotemporally specific manner, within neural systems known to underpin sexually dimorphic behaviors.
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46,XY DSD with Female or Ambiguous External Genitalia at Birth due to Androgen Insensitivity Syndrome, 5alpha-Reductase-2 Deficiency, or 17beta-Hydroxysteroid Dehydrogenase Deficiency: A Review of Quality of Life Outcomes. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2009; 2009:567430. [PMID: 19956704 PMCID: PMC2777017 DOI: 10.1155/2009/567430] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 07/29/2009] [Indexed: 11/17/2022]
Abstract
Disorders of sex development refer to a collection of congenital conditions in which atypical development of chromosomal, gonadal, or anatomic sex occurs. Studies of 46,XY DSD have focused largely on gender identity, gender role, and sexual orientation. Few studies have focused on other domains, such as physical and mental health, that may contribute to a person's quality of life. The current review focuses on information published since 1955 pertaining to psychological well-being, cognition, general health, fertility, and sexual function in people affected by androgen insensitivity syndromes, 5-α reductase-2 deficiency, or 17β-hydroxysteroid dehydrogenase-3 deficiency—reared male or female. The complete form of androgen insensitivity syndrome has been the focus of the largest number of investigations in domains other than gender. Despite this, all of the conditions included in the current review are under-studied. Realms identified for further study include psychological well-being, cognitive abilities, general health, fertility, and sexual function. Such investigations would not only improve the quality of life for those affected by DSD but may also provide information for improving physical and mental health in the general population.
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31
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Lux A, Kropf S, Kleinemeier E, Jürgensen M, Thyen U. Clinical evaluation study of the German network of disorders of sex development (DSD)/intersexuality: study design, description of the study population, and data quality. BMC Public Health 2009; 9:110. [PMID: 19383134 PMCID: PMC2678119 DOI: 10.1186/1471-2458-9-110] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 04/21/2009] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The German Network of Disorders of Sex Development (DSD)/Intersexuality carried out a large scale clinical evaluation study on quality of life, gender identity, treatment satisfaction, coping, and problems associated with diagnoses and therapies in individuals with disorders of sex development (DSD). DSD are a heterogeneous group of various genetic disorders of sex determination or sex differentiation, all of which are rare conditions. In about half of all cases the molecular genetic diagnosis is unknown and diagnosis rests on clinical features. METHODS AND DESIGN The multi-centre clinical evaluation study includes short-term follow-up in some and cross-sectional assessments in all age and diagnostic groups fitting the criteria of DSD. Recruitment was from January 2005 until December 2007 in whole Germany and, additionally, in 2007 in Austria and German-speaking Switzerland. The study consists of a psychosocial inquiry for children, adolescents and their parents, and adults with standardized instruments and the collection of DSD-specific medical data by the attending physician. The main goal was the description of clinical outcomes and the health-care situation of individuals with DSD using a broad generic definition of DSD including all conditions with a mismatch of chromosomal, gonadal and phenotypical sex. 439 children and adolescents, their parents and adults with DSD participated. DISCUSSION The clinical evaluation study represents the most comprehensive study in this clinical field. The paper discusses the study protocol, the data management and data quality as well as the classification used, and it describes the study population. Given the lack of large datasets in rare conditions such as DSD and often biased results from small scale clinical case series, the study aims to generate concrete hypotheses for evidence-based guidelines, which should be tested in further studies.
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Affiliation(s)
- Anke Lux
- Institute for Biometry and Medical Informatics, University Otto-von-Guericke, Leipziger Strasse 44, 39120 Magdeburg, Germany.
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Korte A, Goecker D, Krude H, Lehmkuhl U, Grüters-Kieslich A, Beier KM. Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:834-41. [PMID: 19578420 PMCID: PMC2697020 DOI: 10.3238/arztebl.2008.0834] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 10/15/2008] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric comorbidity. Their clinical course is highly variable. There is controversy at present over theoretical explanations of the causes of GID and over treatment approaches, particularly with respect to early hormonal intervention strategies. METHODS This review is based on a selective Medline literature search, existing national and international guidelines, and the results of a discussion among experts from multiple relevant disciplines. RESULTS As there have been no large studies to date on the course of GID, and, in particular, no studies focusing on causal factors for GID, the evidence level for the various etiological models that have been proposed is generally low. Most models of these disorders assume that they result from a complex biopsychosocial interaction. Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism. The current state of research on this subject does not allow any valid diagnostic parameters to be identified with which one could reliably predict whether the manifestations of GID will persist, i.e., whether transsexualism will develop with certainty or, at least, a high degree of probability. CONCLUSIONS The types of modulating influences that are known from the fields of developmental psychology and family dynamics have therapeutic implications for GID. As children with GID only rarely go on to have permanent transsexualism, irreversible physical interventions are clearly not indicated until after the individual's psychosexual development ist complete. The identity-creating experiences of this phase of development should not be restricted by the use of LHRH analogues that prevent puberty.
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Affiliation(s)
- Alexander Korte
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters
| | | | - Heiko Krude
- Institut für Experimentelle Pädiatrische Endokrinologie
| | - Ulrike Lehmkuhl
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters
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Abstract
Management of intersex disorders
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Affiliation(s)
- I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Box 116, Level 8, Hills Road, Cambridge CB2 2QQ, UK.
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