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Hemesath TP, de Paula LCP, Carvalho CG, Leite JCL, Guaragna-Filho G, Costa EC. Controversies on Timing of Sex Assignment and Surgery in Individuals With Disorders of Sex Development: A Perspective. Front Pediatr 2019; 6:419. [PMID: 30687685 PMCID: PMC6335325 DOI: 10.3389/fped.2018.00419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022] Open
Abstract
Appropriate management of disorders of sex development (DSD) has been a matter of discussion since the first guidelines were published in the 1950s. In the last decade, with the advent of the 2006 consensus, the classical methods, especially regarding timing of surgery and sex of rearing, are being questioned. In our culture, parents of DSD newborns usually want their children to undergo genital surgery as soon as possible after sexual assignment, as surgery helps them to confirm the assigned sex. Developmental psychology theories back this hypothesis. They state that anatomic differences between sexes initiate the very important process of identification with the parent of the same sex. Sex-related endocrinological issues also demand early care. For example, using dihydrotestosterone cream to increase penile length or growth hormone treatment to improve final height require intervention at young ages to obtain better results. Although the timing of surgery remains controversial, recent evidence suggests that male reconstruction should be performed between 6 and 18 months of age. Feminizing surgery is still somewhat controversial. Most guidelines agree that severe virilization requires surgical intervention, while no consensus exists regarding mild cases. Our perspective is that precocious binary sex assignment and early surgery is a better management method. There is no strong evidence for delays and the consequences can be catastrophic in adulthood.
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Affiliation(s)
- Tatiana Prade Hemesath
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Psycology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Leila Cristina Pedroso de Paula
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Endocrinology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Clarissa Gutierrez Carvalho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Julio Cesar Loguercio Leite
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Medical Genetics Service, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Guilherme Guaragna-Filho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Eduardo Corrêa Costa
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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Telles-Silveira M, Knobloch F, Kater CE. Management framework paradigms for disorders of sex development. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:383-90. [PMID: 26331223 DOI: 10.1590/2359-3997000000084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/21/2022]
Abstract
Until 2005, questions regarding medical treatment and diagnostic information on Disorders of Sex Development (DSD) were not systematically discussed with both the patients and their families; however, the way these patients are currently treated have been changing with time. Interventional changes in the clinical-psychotherapeutic-surgical areas of DSD determine not only different medical recommendations but also help to place the patient and the family into the decisional process of therapy. We must consider two paradigmatic periods that have influenced and transformed the clinical management framework of patients with DSD: a) The "Money era" (1955), which emphasized the role of the gonads as the diagnostic criterion, having the environment as determinant of the sex identity; and b) The Chicago Consensus (2005) phase, in which the role of genetics and molecular biology was critical for an early identification, as well as in building a proper sex identity, emphasizing ethical questions and the "stigma culture". In addition, recent data have focused on the importance of interdisciplinarity and statements on questions concerning Human Rights as key factors in treatment decision making. Despite each of these management models being able to determine specific directions and recommendations regarding the clinical handling of these patients, we verify that a composite of these several models is the clinical routine nowadays. In the present paper, we discuss these several paradigms, and pinpoint clinical differences and their unfolding regarding management of DSD patients and their families.
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Affiliation(s)
- Mariana Telles-Silveira
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Felicia Knobloch
- Faculdade de Ciências Humanas e da Saúde, Pontifícia Universidade Católica de São Paulo, São Paulo, SP, Brasil
| | - Claudio E Kater
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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