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Goodman M, Yacoub R, Getahun D, McCracken CE, Vupputuri S, Lash TL, Roblin D, Contreras R, Cromwell L, Gardner MD, Hoffman T, Hu H, Im TM, Prakash Asrani R, Robinson B, Xie F, Nash R, Zhang Q, Bhai SA, Venkatakrishnan K, Stoller B, Liu Y, Gullickson C, Ahmed M, Rink D, Voss A, Jung HL, Kim J, Lee PA, Sandberg DE. Cohort profile: pathways to care among people with disorders of sex development (DSD). BMJ Open 2022; 12:e063409. [PMID: 36130763 PMCID: PMC9494584 DOI: 10.1136/bmjopen-2022-063409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The 'DSD Pathways' study was initiated to assess health status and patterns of care among people enrolled in large integrated healthcare systems and diagnosed with conditions comprising the broad category of disorders (differences) of sex development (DSD). The objectives of this communication are to describe methods of cohort ascertainment for two specific DSD conditions-classic congenital adrenal hyperplasia with 46,XX karyotype (46,XX CAH) and complete androgen insensitivity syndrome (CAIS). PARTICIPANTS Using electronic health records we developed an algorithm that combined diagnostic codes, clinical notes, laboratory data and pharmacy records to assign each cohort candidate a 'strength-of-evidence' score supporting the diagnosis of interest. A sample of cohort candidates underwent a review of the full medical record to determine the score cutoffs for final cohort validation. FINDINGS TO DATE Among 5404 classic 46,XX CAH cohort candidates the strength-of-evidence scores ranged between 0 and 10. Based on sample validation, the eligibility cut-off for full review was set at the strength-of-evidence score of ≥7 among children under the age of 8 years and ≥8 among older cohort candidates. The final validation of all cohort candidates who met the cut-off criteria identified 115 persons with classic 46,XX CAH. The strength-of-evidence scores among 648 CAIS cohort candidates ranged from 2 to 10. There were no confirmed CAIS cases among cohort candidates with scores <6. The in-depth medical record review for candidates with scores ≥6 identified 61 confirmed cases of CAIS. FUTURE PLANS As the first cohort of this type, the DSD Pathways study is well-positioned to fill existing knowledge gaps related to management and outcomes in this heterogeneous population. Analyses will examine diagnostic and referral patterns, adherence to care recommendations and physical and mental health morbidities examined through comparisons of DSD and reference populations and analyses of health status across DSD categories.
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Affiliation(s)
- Michael Goodman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Rami Yacoub
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Darios Getahun
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
| | - Courtney E McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Timothy L Lash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Richard Contreras
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lee Cromwell
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Melissa D Gardner
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Trenton Hoffman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Theresa M Im
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Brandi Robinson
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Fagen Xie
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rebecca Nash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Qi Zhang
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sadaf A Bhai
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Bethany Stoller
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Yijun Liu
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Maaz Ahmed
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - David Rink
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ava Voss
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Hye-Lee Jung
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jin Kim
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - David E Sandberg
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Birnbaum W, Marshall L, Werner R, Kulle A, Holterhus PM, Rall K, Köhler B, Richter-Unruh A, Hartmann MF, Wudy SA, Auer MK, Lux A, Kropf S, Hiort O. Oestrogen versus androgen in hormone-replacement therapy for complete androgen insensitivity syndrome: a multicentre, randomised, double-dummy, double-blind crossover trial. Lancet Diabetes Endocrinol 2018; 6:771-780. [PMID: 30075954 DOI: 10.1016/s2213-8587(18)30197-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Women with complete androgen insensitivity syndrome (CAIS) after gonadectomy have complained about reduced psychological wellbeing and sexual satisfaction. The aim of this study was to compare the effectiveness of hormone-replacement therapy with either androgen or oestrogen in women with 46,XY karyotype and CAIS after gonadectomy. METHODS This national, multicentre, double-blind, randomised crossover trial was performed at three university medical centres and three specialised treatment institutions in Germany. Eligible participants were women aged 18-54 years with 46,XY karyotype, genetically diagnosed CAIS, and removed gonads. Participants were randomly assigned (14:12) by a central computer-based minimisation method to either oestradiol 1·5 mg/day for 6 months followed by crossover to testosterone 50 mg/day for 6 months (sequence A) or to testosterone 50 mg/day for 6 months followed by crossover to oestradiol 1·5 mg/day for 6 months (sequence B). Participants also received oestradiol or testosterone dummy to avoid identification of the active substance. All participants received oestradiol 1·5 mg/day during a 2 months' run-in phase. The primary outcome was mental health-related quality of life, as measured with the standardised German version of the SF-36 questionnaire. Secondary outcomes were psychological wellbeing, as measured with the Brief Symptom Inventory (BSI), sexual function, as measured with the Female Sexual Function Index (FSFI), and somatic effects, such as signs of virilisation and effects on metabolic blood values. The primary analysis included all patients who were available at least until visit 5, even if protocol violations occurred. The safety analysis included all patients who received at least oestradiol during the run-in phase. This trial is registered with the German Clinical Trials Register, number DRKS00003136, and with the European Clinical Trials Database, number 2010-021790-37. FINDINGS We enrolled 26 patients into the study, with the first patient enrolled on Nov 7, 2011, and the last patient leaving the study on Jan 23, 2016. 14 patients were assigned to sequence A and 12 were assigned to sequence B. Ten participants were withdrawn from the study, two of whom attended at least five visits and so could be included in the primary analysis. Mental health-related quality of life did not differ between treatment groups (linear mixed model, p=0·794), nor did BSI scores for psychological wellbeing (global severity index, p=0·638; positive symptom distress index, p=0·378; positive symptom total, p=0·570). For the FSFI, testosterone was superior to oestradiol only in improving sexual desire (linear mixed model, p=0·018). No virilisation was observed, and gonadotrophin concentrations remained stable in both treatment groups. Oestradiol and testosterone concentrations changed substantially during the study in both treatment groups. 28 adverse events were reported for patients receiving oestradiol (23 grade 1 and five grade 2), and 38 adverse events were reported for patients receiving testosterone (34 grade 1, three grade 2, and one grade 3). One serious adverse event (fibrous mastopathy) and 20 adverse events (16 grade 1 and four grade 2) were reported during the run-in phase, and 12 adverse events during follow-up (nine grade 1 and three grade 2). INTERPRETATION Testosterone was well tolerated and as safe as oestrogen for hormone-replacement therapy. Testosterone can be an alternative hormone substitution in CAIS, especially for woment with reduced sexual functioning. FUNDING German Federal Ministry of Education and Research.
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Affiliation(s)
- Wiebke Birnbaum
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Louise Marshall
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany
| | - Alexandra Kulle
- Department of Paediatrics, Christian-Albrechts-University, Kiel, Germany
| | | | - Katharina Rall
- Department of Women's Health, Centre for Rare Female Genital Malformations, Women's University Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Birgit Köhler
- Department of Pediatric Endocrinology and Diabetology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annette Richter-Unruh
- Paediatric Endocrinology, Department of Paediatrics, Universitätsklinikum Münster, Westfälische Wilhelms-Universität Münster, Germany
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Division of Paediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Division of Paediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Matthias K Auer
- Research Group Clinical Neuroendocrinology, Max Planck Institute of Psychiatry, Munich, Germany
| | - Anke Lux
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Siegfried Kropf
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Germany.
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Khorashad BS, Aghili Z, Kreukels BPC, Reid AG, Roshan GM, Hiradfar M, Talaei A, Cohen Kettenis PT. Mental Health and Disorders of Sex Development/Intersex Conditions in Iranian Culture: Congenital Adrenal Hyperplasia, 5-α Reductase Deficiency-Type 2, and Complete Androgen Insensitivity Syndrome. Arch Sex Behav 2018; 47:931-942. [PMID: 29294229 DOI: 10.1007/s10508-017-1139-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 09/12/2017] [Accepted: 12/14/2017] [Indexed: 06/07/2023]
Abstract
Sixty-one patients (22 patients with congenital adrenal hyperplasia [CAH] with a mean age of 14.86 years [range, 5-23], 20 patients with 5-α reductase deficiency type 2 [5α-RD-2] with a mean age of 19.5 years [range, 5-29], and 19 patients with complete androgen insensitivity syndrome [CAIS] with a mean age of 18.26 years [range, 5-28]) were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, the Structured Clinical Interview for DSM-IV Axis I, Axis II, and the Global Assessment Functioning Scale. All participants were female-assigned at birth. Ten patients (16.4%) transitioned to the male gender. Overall, 68% of patients had one or more lifetime Axis I disorders, including 63.6% of the CAH participants, 90% of 5α-RD-2 participants, and 52.6% of the CAIS participants. The most commonly observed were affective disorders (27.9%), gender identity disorder (27.9%), and anxiety (16.4%). Our study demonstrates that mental health of Iranian patients with DSD is at risk. This might be due to the fact that patients with DSD conditions are mostly treated medically and their mental health is often superficially addressed in developing countries such as Iran, at least in the past. We argue that it is important to pay attention to the mental health issues of patients with DSD and focus on specific issues, which may vary cross-culturally.
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Affiliation(s)
- Behzad S Khorashad
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran.
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran.
| | - Zahra Aghili
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Alistair G Reid
- Molecular Pathology Unit, Liverpool Clinical Laboratories, Liverpool, UK
| | - Ghasem M Roshan
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Mehran Hiradfar
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Peggy T Cohen Kettenis
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
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Engberg H, Strandqvist A, Nordenström A, Butwicka A, Nordenskjöld A, Hirschberg AL, Frisén L. Increased psychiatric morbidity in women with complete androgen insensitivity syndrome or complete gonadal dysgenesis. J Psychosom Res 2017; 101:122-127. [PMID: 28867417 DOI: 10.1016/j.jpsychores.2017.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/04/2017] [Accepted: 08/06/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Knowledge concerning mental health outcomes is important to optimize the health of individuals with disorders or differences of sex development (DSD). Thus, the aim of this study was to estimate if the prevalence of psychiatric morbidity in adult women diagnosed with complete androgen insensitivity syndrome (CAIS) or complete gonadal dysgenesis (46,XY GD and 46,XX GD) differs from that in women with premature ovarian insufficiency (POI) or age-matched population controls. METHODS This cross-sectional study was conducted at the Karolinska University Hospital, Stockholm, Sweden, and included 33 women with different DSDs: 20 CAIS, 6 46,XY GD, 7 46,XX GD, 21 women with POI and 61 population-derived controls. Psychiatric morbidity was assessed using the Mini International Neuropsychiatric Interview plus (MINI+). To complement the MINI+, three self-report questions were used to evaluate current and previous psychiatric history. Results are presented as p values and estimated risks (odds ratio [OR], 95% confidence intervals [CI]) of psychiatric conditions among women with CAIS or GD in comparison with women with POI and age-matched population-derived controls. RESULTS Twenty-eight of the 33 women (85%) with CAIS or GD met the criteria for at least one psychiatric disorder according to the MINI+, with depression and anxiety disorders being most common. This was significantly higher compared with population controls (52%) (OR 5.1, 95% CI 1.7-14.9), but not compared to women with POI, who had a high frequency of psychiatric diagnoses (76%). CONCLUSION The increased psychiatric morbidity in women with CAIS and GD highlights the need for clinical awareness of the psychiatric vulnerability in these patients.
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Affiliation(s)
- Hedvig Engberg
- Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Child and Adolescent Psychiatry Research Center, Gävlegatan 22B, SE-113 30 Stockholm, Sweden.
| | - Anna Strandqvist
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Psychology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| | - Anna Nordenström
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Agnieszka Butwicka
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Child Psychiatry, Medical University of Warsaw, Żwirki i Wigury 61, PL-02-091 Warsaw, Poland.
| | - Agneta Nordenskjöld
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Child and Adolescent Psychiatry Research Center, Gävlegatan 22B, SE-113 30 Stockholm, Sweden.
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Chen MJ, Vu BMK, Axelrad M, Dietrich JE, Gargollo P, Gunn S, Macias CG, McCullough LB, Roth DR, Sutton VR, Karaviti LP. Androgen Insensitivity Syndrome: Management Considerations from Infancy to Adulthood. Pediatr Endocrinol Rev 2015; 12:373-387. [PMID: 26182482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Androgen insensitivity syndrome (AIS) is an undervirilization syndrome in individuals with 46, XY karyotype. The undervirilization can be complete feminization or incomplete virilization with grades of ambiguity. AIS is caused by mutations in the androgen receptor, resulting in resistance to the physiologic activities of androgens. Differing degrees of resistance lead to three phenotypes: a complete form with female-appearing external genitalia, a partial form with a wide range of virilization, and a mild form with only minor undervirilization. AIS presents different challenges depending on whether resistance is complete or partial. Challenges include sex assignment, which impacts other medical decisions such as gonadectomy, hormonal replacement, and other surgical interventions. This review describes medical, psychosocial, and ethical concerns for each stage of development in complete and partial AIS, from the neonatal period to adulthood. These aspects of care should be addressed within an ethical framework by a multidisciplinary team, with the patients and families being the stakeholders in the decision-making process. We use the GRADE system when appropriate to appraise the existing evidence and provide recommendations and guidelines for management of AIS and appropriate transition of patients from pediatric to adult care.
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Hamann S, Stevens J, Vick JH, Bryk K, Quigley CA, Berenbaum SA, Wallen K. Brain responses to sexual images in 46,XY women with complete androgen insensitivity syndrome are female-typical. Horm Behav 2014; 66:724-30. [PMID: 25284435 DOI: 10.1016/j.yhbeh.2014.09.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/29/2014] [Accepted: 09/05/2014] [Indexed: 01/27/2023]
Abstract
Androgens, estrogens, and sex chromosomes are the major influences guiding sex differences in brain development, yet their relative roles and importance remain unclear. Individuals with complete androgen insensitivity syndrome (CAIS) offer a unique opportunity to address these issues. Although women with CAIS have a Y chromosome, testes, and produce male-typical levels of androgens, they lack functional androgen receptors preventing responding to their androgens. Thus, they develop a female physical phenotype, are reared as girls, and develop into women. Because sexually differentiated brain development in primates is determined primarily by androgens, but may be affected by sex chromosome complement, it is currently unknown whether brain structure and function in women with CAIS is more like that of women or men. In the first functional neuroimaging study of (46,XY) women with CAIS, typical (46,XX) women, and typical (46, XY) men, we found that men showed greater amygdala activation to sexual images than did either typical women or women with CAIS. Typical women and women with CAIS had highly similar patterns of brain activation, indicating that a Y chromosome is insufficient for male-typical human brain responses. Because women with CAIS produce male-typical or elevated levels of testosterone which is aromatized to estradiol these results rule out aromatization of testosterone to estradiol as a determinate of sex differences in patterns of brain activation to sexual images. We cannot, however, rule out an effect of social experience on the brain responses of women with CAIS as all were raised as girls.
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Affiliation(s)
- Stephan Hamann
- Psychology Department, Emory University, Atlanta, GA, USA.
| | | | | | - Kristina Bryk
- Psychology Department, The Pennsylvania State University, University Park, PA, USA
| | | | - Sheri A Berenbaum
- Psychology Department, The Pennsylvania State University, University Park, PA, USA
| | - Kim Wallen
- Psychology Department, Emory University, Atlanta, GA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Khera M. Patients with testosterone deficit syndrome and depression. ARCH ESP UROL 2013; 66:729-736. [PMID: 24047633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Prevalence of depression in men increases with age, so does the prevalence of hypogonadism. Depression and anxiety are the most common psychopathological symptoms associated with male hypogonadism.The question is whether the age-related gradual decline in testosterone levels contributes to the rising rate of depression in older men. Many studies have demonstrated the improvement in depressive symptoms in hypogonadal men with testosterone supplementation. However, a subpopulation of hypogonadal men appear to be better responders to TRT when treated for depression. Testosterone deficiency is associated with numerous non-specific symptoms including decline in libido, erectile dysfunction, increased fat deposition, decreased muscle mass, decreased energy and depression. The relationship between increased depressive symptoms and declining testosterone levels is complex because many conditions are independently associated with depression and testosterone deficiency. These conditions include medical illnesses, such as HIV/AIDS, and obesity, stress, smoking, and alcohol abuse. While the literature does not support a consistent relationship between testosterone levels and depressive symptoms most studies do suggest that lower testosterone levels are associated with depressive symptoms. Furthermore, TRT has been shown to improve depressive symptoms in most men. This could be due to the fact that testosterone is a modulator of GABAA receptors and inhibits 5-HT3 receptors centrally. However there appears to be a subpopulation of depressed male patients that tend to respond best to TRT. These patients include men who have HIV/AIDS, mild depression, more severe testosterone deficiency, use transdermal testosterone as opposed to IM testosterone, and those not responding to SSRIs. However, patients taking SSRIs also experience a significant improvement in depressive symptoms once treated with TRT. Men with depressive symptoms and testosterone deficiency syndrome should be given a trial of testosterone replacement therapy for at least 3 months as TRT alone may improve clinical symptoms of depression. Furthermore, men already on SSRIs may also experience further improvement in depressive symptoms after initiating TRT.
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Affiliation(s)
- Mohit Khera
- Assistant Professor of Urology. Diector Laboratory for Andrology Research. Medical Director Hospital for Specialized Surgey .Houston .Arizona.USA
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Abstract
An autobiographical reflection on the experience of being diagnosed as intersex, this essay considers the waiting room an apt metaphor for lives shaped by medical understandings of queer corporealities. Drawing upon the work of Gayle Salamon, Malatino develops the concept of sexual synecdoche as a useful analytic tool for considering the operations of medical pathologization in the realm of non-normative gender. She concludes with a discussion of queer becoming as an alternative ontology of gendered being that offers a resistant, coalitional way beyond contemporary, problematic institutionalized understandings of intersex subjectivities.
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Affiliation(s)
- Hilary Malatino
- Department of Gender Studies, Indiana University Bloomington, Bloomington, IN 47401, USA.
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Joseph AA, Shabir I, Marumadi E, Dada R, Ammini AC, Mehta M. Psychosexual outcomes in three siblings with partial androgen insensitivity syndrome: impact of nature versus nurture. J Pediatr Endocrinol Metab 2013; 26:915-20. [PMID: 23729553 DOI: 10.1515/jpem-2013-0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/22/2013] [Indexed: 11/15/2022]
Abstract
There are few reports of adults with disorders of sexual development (DSD). Here we describe the clinical profile and results of psychological assessment of three siblings with 46, XY DSD caused by partial androgen insensitivity syndrome (PAIS). The elder sibling (aged 22 years) was reared as female, while the middle and youngest siblings (17 and 18 years of age), were reared as males. The gender identity was concordant with the sex of rearing. There was no gender dysphoria. The psychological distress that our patients experienced was due to the limitations placed on them by their medical condition. It did not permit them to experience various facets of being either male or female completely. The younger siblings reared as males had additional problems of gynecomastia and lack of male secondary sexual development.
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Mattila AK, Fagerholm R, Santtila P, Miettinen PJ, Taskinen S. Gender identity and gender role orientation in female assigned patients with disorders of sex development. J Urol 2012; 188:1930-4. [PMID: 22999536 DOI: 10.1016/j.juro.2012.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE Gender identity and gender role orientation were assessed in 24 female assigned patients with disorders of sex development. MATERIALS AND METHODS A total of 16 patients were prenatally exposed to androgens, of whom 15 had congenital adrenal hyperplasia and 1 was virilized due to maternal tumor. Eight patients had 46,XY karyotype, of whom 5 had partial and 3 had complete androgen insensitivity syndrome. Gender identity was measured by the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults with 167 female medical students as controls, and gender role was assessed by the femininity and masculinity subscales of the 30-item Bem Sex Role Inventory with 104 female and 64 male medical students as controls. RESULTS No patient reached the cutoff for gender identity disorder on the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. However, patients with 46,XY karyotype demonstrated a somewhat more conflicted gender identity, although the overall differences were relatively small. As to gender role orientation, patients with complete androgen insensitivity syndrome had high scores on the femininity and masculinity scales of the Bem Sex Role Inventory, which made them the most androgynous group. CONCLUSIONS Our findings, although clinically not clear cut, suggest that patients with disorders of sex development are a heterogeneous group regarding gender identity and gender role outcomes, and that this issue should be discussed with the family when treatment plans are made.
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Affiliation(s)
- Aino K Mattila
- School of Health Sciences, University of Tampere and Gender Identity Unit, Department of Adult Psychiatry, University Hospital of Tampere, Tampere, Finland
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Robinson S, Penatti CAA, Clark AS. The role of the androgen receptor in anabolic androgenic steroid-induced aggressive behavior in C57BL/6J and Tfm mice. Horm Behav 2012; 61:67-75. [PMID: 22057031 DOI: 10.1016/j.yhbeh.2011.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 10/14/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
Humans self-administer anabolic androgenic steroids (AAS) at superphysiological doses for the purpose of building muscle mass and enhancing physique whereas considerably lower doses of AAS are prescribed in the clinic to treat a variety of disorders. A number of studies have demonstrated that individual AAS influence aggressive behavior in rats and mice, but few studies have examined the aggression-enhancing effects of combinations of AAS. Using the resident-intruder paradigm, Experiment 1 determined whether a cocktail of commonly abused AAS increased aggressive behavior in gonadally-intact male C57BL/6J mice and examined whether the androgen receptor (AR) was involved. Mice given either AAS cocktail or the cocktail and the AR antagonist, flutamide, for 6 weeks were subject to three weekly tests in which the percentage of mice that fought, the latency to initiate an aggressive event and the number of aggressive events per 5-min-fight session were recorded. In C57BL/6J mice, 6 weeks of AAS administration increased the likelihood of fighting, however, within the subset of mice that engaged in aggression, AAS did not specifically modulate the latency to fight or the number of aggressive events per fight. In addition, co-administration of flutamide only slightly altered the likelihood that mice given AAS will initiate a fight. Experiment 2 examined the aggression-promoting effects of AAS in gonadally-intact adult testicular feminization mutant (Tfm) mice, which are deficient in functional ARs. Overall, fewer Tfm mice compared to C57BL/6J mice fought in both drug conditions (vehicle or AAS). Taken together, these data suggest that given the presence of AR during development, AAS enhance adult male aggression in C57BL/6J mice through AR-independent and AR-dependent pathways. In contrast, in adult Tfm mice, the likelihood of AAS-enhanced aggression in adulthood is significantly reduced.
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Affiliation(s)
- Siobhan Robinson
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH 03755, USA
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Zuloaga DG, Poort JE, Jordan CL, Breedlove SM. Male rats with the testicular feminization mutation of the androgen receptor display elevated anxiety-related behavior and corticosterone response to mild stress. Horm Behav 2011; 60:380-8. [PMID: 21801726 PMCID: PMC3171185 DOI: 10.1016/j.yhbeh.2011.07.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 06/30/2011] [Accepted: 07/07/2011] [Indexed: 11/16/2022]
Abstract
Testosterone influences the hypothalamic-pituitary-adrenal axis, anxiety-related behavior, and sensorimotor gating in rodents, but little is known about the role of the androgen receptor (AR) in mediating these influences. We compared levels of the stress hormone corticosterone at baseline and following exposure to a novel object in an open field in wild type (wt) male and female rats, and male rats with the testicular feminization mutation (Tfm) of the AR, which disables its function. Basal corticosterone was equivalent in all groups, but exposure to a novel object in an open field elicited a greater increase in corticosterone in Tfm males and wt females than in wt males. Tfm males also showed increased behavioral indices of anxiety compared to wt males and females in the test. Analysis of the immediate early gene c-Fos expression after exposure to a novel object revealed greater activation in Tfm males than wt males in some regions (medial preoptic area) and lesser activation in others (dentate gyrus, posterodorsal medial amygdala). No differences were found in a measure of sensorimotor gating (prepulse inhibition of the acoustic startle response), although Tfm males had an increased acoustic startle response compared to wt males and females. These findings demonstrate that ARs play a role in regulating anxiety-related behaviors, as well as corticosterone responses and neural activation following exposure to a mild stressor in rats.
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Affiliation(s)
- Damian G Zuloaga
- Department of Psychology and Program in Neuroscience, 108 Giltner Hall, Michigan State University, East Lansing, MI 48824-1101, USA.
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T'Sjoen G, De Cuypere G, Monstrey S, Hoebeke P, Freedman FK, Appari M, Holterhus PM, Van Borsel J, Cools M. Male gender identity in complete androgen insensitivity syndrome. Arch Sex Behav 2011; 40:635-638. [PMID: 20358272 DOI: 10.1007/s10508-010-9624-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/06/2010] [Accepted: 03/17/2010] [Indexed: 05/29/2023]
Abstract
Women and girls with complete androgen insensitivity syndrome (CAIS) invariably have a female typical core gender identity. In this case report, we describe the first case of male gender identity in a CAIS individual raised female leading to complete sex reassignment involving both androgen treatment and phalloplasty. CAIS was diagnosed at age 17, based on an unambiguously female phenotype, a 46,XY karyotype, and a 2660delT androgen receptor (AR) gene mutation, leading to a premature stop in codon 807. Bilateral gonadectomy was performed but a short period of estrogen treatment induced a negative emotional reaction and treatment was stopped. Since the age of 3, childhood-onset cross gender behavior had been noticed. After a period of psychotherapy, persisting male gender identity was confirmed. There was no psychiatric co-morbidity and there was an excellent real life experience. Testosterone substitution was started, however without inducing any of the desired secondary male characteristics. A subcutaneous mastectomy was performed and the patient received phalloplasty by left forearm free flap and scrotoplasty. Testosterone treatment was continued, without inducing virilization, and bone density remained normal. The patient qualifies as female-to-male transsexual and was treated according to the Standards of Care by the World Professional Association for Transgender Health with good outcome. However, we do not believe that female sex of rearing as a standard procedure should be questioned in CAIS. Our case challenges the role of a functional AR pathway in the development of male gender identity.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology, Center for Sexology and Genderproblems, Ghent University Hospital, Belgium.
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16
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Joseph AA, Kulshreshtha B, Mehta M, Ammini AC. Sex of rearing seems to exert a powerful influence on gender identity in the absence of strong hormonal influence: report of two siblings with PAIS assigned different sex of rearing. J Pediatr Endocrinol Metab 2011; 24:1071-5. [PMID: 22308869 DOI: 10.1515/jpem.2011.287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is an ongoing debate regarding the relative contribution of nurture over nature in development of gender identity. Patients with partial androgen insensitivity syndrome (PAIS) have ambiguous genitalia and are known to be reared as male or female. Familial cases of PAIS sharing common hormonal defects are usually reared in the same sex. Here, we describe two siblings with PAIS, one reared as a male and the other as female. These two siblings presented at adolescence. Gender identity was concordant with the sex of rearing for both. The male sibling was distressed with gynecomastia that had disrupted his social life. The sex of rearing seems to have played a predominant role in the formation of gender identity in these two patients with PAIS.
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Affiliation(s)
- Angela Ann Joseph
- Department of Psychiatry, All India Institute of Medical Sciences, Delhi, India
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Abstract
OBJECTIVES We aim to provide an understanding of the psychological sequela of androgen insensitivity syndrome (AIS) in phenotypic females in order to begin to inform psychosocial health care services. DESIGN Eight adult women with AIS were recruited through the Androgen Insensitivity Syndrome Support Group-United Kingdom (AISSG-UK). Data was collected via two semi-structured interviews with each woman. METHODS Transcripts were analysed using grounded theory and a conceptual model was developed which suggests a way of understanding the AIS distress experienced by the participants. RESULTS The pivotal concept is a woman's fear of devaluation. This is connected to her level of adaptation and perception of having a compromised womanhood. These, in turn, are related to her medical management and involvement with others via a support group and in talking about AIS. CONCLUSIONS Participants showed a clear preference for open communication about their condition throughout the process of medical management. We recommend sensitive, pacing of information to allow young women and their families to make informed decisions about treatment and a realistic adaptation to life with AIS.
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Affiliation(s)
- Julie Alderson
- Leeds Teaching Hospitals, University of Leeds, and Department of Clinical and Health Psychology, St James' University Hospital, Leeds, UK.
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18
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Meyer-Bahlburg HFL. Gender outcome in 46,XY complete androgen insensitivity syndrome: comment on T'Sjoen et al. (2010). Arch Sex Behav 2010; 39:1221-1224. [PMID: 20552263 DOI: 10.1007/s10508-010-9640-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Abstract
Psychosocial aspects of the treatment of disorders of sex development (DSDs) concern gender assignment, information management and communication, timing of medical interventions, consequences of surgery, and sexuality. Although outcome is often satisfactory, a variety of medical and psychosocial factors may jeopardise the psychological development of children with DSDs. This sometimes results in the desire to change gender later in life. The clinical management of gender dysphoria in individuals with DSD may profit from methods and insights that have been developed for gender dysphoric individuals without DSD. In DSD care, clinical decisions are often made with long-lasting effects on quality of life and should be based on empirical evidence. Yet, such evidence (e.g., regarding gender assignment, information management and timing of surgery) is largely non-existent. DSD-specific protocols and educational materials need to be developed to standardise and evaluate interventions in order to facilitate decision making of professionals and individuals with DSD and enhance psychosocial care in this area.
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Affiliation(s)
- P T Cohen-Kettenis
- Department of Medical Psychology, VU University, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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20
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Meyer-Bahlburg HFL. Concerns regarding gender change to male in a 46,XY child with complete androgen insensitivity syndrome: comment on Kulshreshtha et al. (2009). Arch Sex Behav 2009; 38:876-877. [PMID: 19705270 DOI: 10.1007/s10508-009-9533-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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21
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Kulshreshtha B, Philibert P, Eunice M, Khandelwal SK, Mehta M, Audran F, Paris F, Sultan C, Ammini AC. Apparent male gender identity in a patient with complete androgen insensitivity syndrome. Arch Sex Behav 2009; 38:873-875. [PMID: 19636694 DOI: 10.1007/s10508-009-9526-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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22
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Hamson DK, Csupity AS, Ali FM, Watson NV. Partner preference and mount latency are masculinized in androgen insensitive rats. Physiol Behav 2009; 98:25-30. [PMID: 19375435 DOI: 10.1016/j.physbeh.2009.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 04/02/2009] [Accepted: 04/08/2009] [Indexed: 11/18/2022]
Abstract
The sexual motivation of male rats may be inferred from a preference to stay in proximity to estrous female partners, and also from a short latency to show mounting behavior. Here, partner preference was assessed in rats carrying the testicular feminization mutation (TFM), and compared to wild type (WT) males in one version of this paradigm, and WT females and males in another version. Additionally, mount latency was quantified in the TFMs and compared to WT males in order to assess arousal levels, as this has not been previously reported. When presented with a choice between proximity to an estrous or non-estrous female, WT males and TFMs demonstrated similar preferences for the estrous female. Estrous females, conversely, preferred to spend time with the WT male. In agreement with previous reports we observed several sexual performance deficits in the TFMs, but mount latencies were in the male range. Given that the TFMs reliably choose to spend time with the estrous female in the partner preference tests, and that they display normal arousal levels (reflected in masculinized mount latencies), the data suggest the motivation to engage in sexual behavior is masculine in the TFM rat and that possession of functional androgen receptors is not crucial in these behaviors.
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Affiliation(s)
- Dwayne K Hamson
- Hormones and Behavior Lab, Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
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23
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Giwercman YL, Svensson J. [Androgen insensitivity syndrome]. Tidsskr Nor Laegeforen 2008; 128:581-585. [PMID: 18311203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Androgen insensitivity is caused by mutations in the androgen receptor gene, and is a common etiological factor to ambiguous genitalia in the newborn. This article discusses the role of androgens in sex differentiation, the structure and function of the androgen receptor, the genetic background to androgen insensitivity as well as clinical aspects. MATERIAL AND METHODS The article is based on literature retrieved from PubMed, the androgen receptor mutation database and the authors' own research and clinical experience. RESULTS AND DISCUSSION Androgen insensitivity encompasses a wide spectrum of clinical manifestations. Besides exclusion of possible differential diagnosis, the diagnostic work-up includes a clinical assessment of the androgen receptor's susceptibility to androgen stimulation as well as molecular genetic analysis of the androgen receptor gene. The condition should be managed with a multidisciplinary approach by teams competent to treat children with disorders of sexual development.
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Affiliation(s)
- Yvonne Lundberg Giwercman
- Molekylärmedicinsk reproduktionsforskning Institutionen för kliniska vetenskaper Lunds Universitet S-20502 Malmö.
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Brinkmann L, Schuetzmann K, Richter-Appelt H. Gender assignment and medical history of individuals with different forms of intersexuality: evaluation of medical records and the patients' perspective. J Sex Med 2007; 4:964-80. [PMID: 17627743 DOI: 10.1111/j.1743-6109.2007.00524.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Until now, there are only few studies that focus on the specific treatment experiences of people with intersexuality and evaluate their outcome in terms of psychological, physical, and social well-being. Further, the presentation of the patients' perspective is often neglected in research. AIM Overview of preliminary results of the Hamburg-Intersex-Study on gender assignment and medical history of adult subjects with intersexuality (disorders of sex development), as well as the patients retrospectively stated thoughts and feelings regarding these interventions. MAIN OUTCOME MEASURES Medical records from participants of the study were analyzed. The subjective attitudes and evaluation of the treatment measures were assessed with a self-constructed questionnaire. Data on psychological well-being were measured with the Brief Symptom Inventory. METHODS In total, 37 adult participants (mean age 30.6 years) with following diagnosis were included: congenital adrenal hyperplasia, complete and partial androgen insensitivity syndrome, gonadal dysgenesis and disturbances of the androgen biosynthesis, such as 5 alpha reductase deficiency and 17 beta hydroxysteroid deficiency. RESULTS The majority of participants had (often multiple) genital surgery to correct the appearance of their genitalia and/or to enable sexual functioning. The diagnostic groups differ not only in amount and invasiveness of experienced surgical and medical treatment but also in the subjective and retrospective evaluation of the treatment measures and in the amount of reported psychological distress. CONCLUSION Many subjects stated to have experienced the medical procedures and care very negatively, whereby the aspects of secrecy, untruthfulness, and concealment were stated as most difficult and burdening.
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Affiliation(s)
- Lisa Brinkmann
- Institute for Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Hospital Hamburg-Eppendorf, D-20246 Hamburg, Germany
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Abstract
OBJECTIVE The aim of this study was to assess the quality of life and psychosocial well-being in women with disorders of sex development (DSD). DESIGN An open case-control study. METHODS Social and psychiatric information was collected via a structured interview from 70 Danish women diagnosed with DSD, 70 controls matched on sex, age, and school education, and six women with isolated genital malformations. Quality of life and mental distress were assessed by 'Quality of Life-Assessment of Growth Hormone Deficiency in Adults' (QoL-AGHDA) and three symptom scales from the 'Hopkins Symptom Checklist' (SCL-90-R; i.e. somatization, depression, and anxiety) respectively. For both measures, higher scores reflected poorer outcomes. RESULTS Present relationships and having children were less frequent in patients than in controls (P = 0.02 and P < 0.001 respectively). Previous suicidal thoughts (P = 0.002) and a higher frequency of psychological/psychiatric counseling for severe problems (P = 0.06) were more frequently reported in patients than in controls. The mean QoL-AGHDA score was significantly higher in patients than in controls (5.5 vs 2.9; P = 0.002), especially for congenital adrenal hyperplasia (CAH) females (P = 0.01) and virilized 46,XX and 46,XY females (P = 0.04). The total SCL score was higher in patients than in controls (mean 23.2 vs 20.0), reaching significance for anxiety (mean 6.3 vs 4.3, P = 0.03) with highest score in CAH (P = 0.01). CONCLUSION An impaired quality of life and more affective distress were observed especially in CAH patients and virilized 46,XX and 46,XY females. This may be caused by trauma from distressing diagnostic procedures, the chronic illnesses per se, and psychosocial consequences of the disorders.
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Affiliation(s)
- Trine H Johannsen
- University Department of Growth and Reproduction, GR-5064, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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26
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Byne W. Developmental endocrine influences on gender identity: implications for management of disorders of sex development. Mt Sinai J Med 2006; 73:950-9. [PMID: 17195880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
When a baby is born, the first medical pronouncement is usually, "It's a boy," or "It's a girl." In most cases, this pronouncement is based simply upon the appearance of the child's external genitalia. Due to variations in the process of sexual differentiation, sometimes the gender that should be assigned is not apparent from inspection of the external genitalia, either because they are "ambiguous" or because their appearance is not congruent with the internal anatomy. Decisions must be made not only about the most appropriate gender to assign the infant but also about the medical and rearing practices that will facilitate optimal psychological development and quality of life for the affected individual. This article will review the approach to managing gender disorders that has evolved since the 1950s. Three issues are identified as central to current shifts that are occurring in the management of these disorders: (a) increased understanding of the biological substrates of gender identity; (b) questions regarding the indications for irreversible cosmetic genital surgeries as a means of reinforcing gender assignments in infancy, and (c) ethical issues pertaining to informed consent and who is entitled to give it, particularly with regard to surgical gender reassignments in infancy. In keeping with the neuropsychiatry theme of this issue, the focus of this article is on prenatal sexual differentiation of the brain as it pertains to the question of psychosexual neutrality at birth.
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Affiliation(s)
- William Byne
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA.
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Abstract
For decades, sex assignment in children with intersex conditions has depended more on surgical possibilities than on other criteria, since it was assumed that children are psychosexually neutral at birth. Adults with intersex conditions and professionals in the field have increasingly criticized this policy after the publication of studies suggesting that prenatal brain exposure to sex hormones determines gender development. Although prenatal brain exposure to androgens plays some part in the development of gender role behaviour, the current evidence is not in line with the idea of determination of gender identity through prenatal sex steroid exposure. Recent reviews on gender dysphoria and gender change in patients with intersex conditions show that initial gender assignment still seems to be the best predictor of adult gender identity.
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Affiliation(s)
- Peggy Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
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28
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Abstract
It is always going to be difficult for a woman to find out that she is genetically male. What are the ethical issues generated by being confronted by outdated practice on disclosure?
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Affiliation(s)
- Jennifer Conn
- Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria 3010, Australia
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29
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Abstract
This review article answers three questions relevant to the medical management and care of individuals born with complete androgen insensitivity syndrome (CAIS), partial androgen insensitivity syndrome (PAIS), or a micropenis: (1) Do any of these individuals reassign themselves from their initial gender assignment? (2) Do more reassign than the ones who do not? (3) Is there evidence of gender dysphoria in those who do not self-initiate reassignment? Reviewed were all articles on CAIS, PAIS, and micropenis cited in K. J. Zucker (1999) plus articles published through 2004. There were no documented cases of gender change in individuals with CAIS (N= 156 females) or micropenis (N= 89: 79 males, 10 females). Nine (9.1%) out of 99 individuals with PAIS changed gender. Thus, self-initiated gender reassignment was rare. Gender dysphoria also appears to be a rare occurrence. The best predictor of adult gender identity in CAIS, PAIS, and micropenis is initial gender assignment.
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Affiliation(s)
- Tom Mazur
- Department of Pediatrics, School of Medicine and Biomedical Sciences, University of Buffalo and The Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA.
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30
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Baratz AB. Sex determination, differentiation, and identity. N Engl J Med 2004; 350:2204-6; author reply 2204-6. [PMID: 15156588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Imperato-McGinley J. 5alpha-reductase-2 deficiency and complete androgen insensitivity: lessons from nature. Adv Exp Med Biol 2003; 511:121-31; discussion 131-4. [PMID: 12575759 DOI: 10.1007/978-1-4615-0621-8_8] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Affiliation(s)
- Douglas A Husmann
- Division of Pediatric Urology, Mayo Clinic, Rochester, Minnesota, USA
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Melo KFS, Mendonca BB, Billerbeck AEC, Costa EMF, Inácio M, Silva FAQ, Leal AMO, Latronico AC, Arnhold IJP. Clinical, hormonal, behavioral, and genetic characteristics of androgen insensitivity syndrome in a Brazilian cohort: five novel mutations in the androgen receptor gene. J Clin Endocrinol Metab 2003; 88:3241-50. [PMID: 12843171 DOI: 10.1210/jc.2002-021658] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Androgen insensitivity syndrome (AIS) is caused by mutations in the androgen receptor gene and is associated with a variety of phenotypes in 46,XY individuals, ranging from phenotypic women [complete form (CAIS)] to men with minor degrees of undervirilization or infertility [partial form (PAIS)]. We studied 32 subjects with male pseudohermaphroditism from 20 families (9 CAIS, 11 PAIS) with the following criteria for AIS: 46,XY karyotype, normal male basal and human chorionic gonadotropin-stimulated levels of serum testosterone and steroid precursors, gynecomastia at puberty, and, in prepubertal patients, a family history suggestive of X-linked inheritance. The entire coding region of the androgen receptor gene was analyzed, and mutations were found in all families with CAIS and in eight of 11 families with PAIS. Fifteen different mutations were identified, including five (S119X, T602P, L768V, I898F, and P904V) that have not been described previously. Detailed clinical and hormonal features were compared with genotype in 25 subjects with AIS and confirmed by mutational analysis. LH hormone levels and the LH x testosterone product were high in all postpubertal subjects with AIS. All subjects with PAIS maintained at postpubertal age the gender identity and social sex that was assigned to them in infancy, in contrast to other forms of pseudohermaphroditism.
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Affiliation(s)
- Karla F S Melo
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-900, Brasil
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35
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Abstract
OBJECTIVE To investigate sexual function in women with complete androgen insensitivity syndrome (CAIS) and to investigate the prevalence of factors that might contribute to sexual difficulties. DESIGN Cross sectional survey and clinical examination. SETTING Tertiary hospital multidisciplinary intersex clinic and an international peer support group for CAIS. PATIENT(S) Sixty-six adult women with CAIS. INTERVENTION(S) Self-completed survey of sexual function, genital normality perceptions, and compliance and satisfaction with vaginal hypoplasia treatments. Hospital case notes review, and genital examination for prevalence of vaginal and clitoral hypoplasia. MAIN OUTCOME MEASURE(S) Golombok-Rust Inventory of Sexual Satisfaction (GRISS) scores of study participants were compared against the scores of the test validation population (as control). In physical examination participants, anatomical dimensions were assessed against published normal values for clitoral and vaginal sizes. RESULT(S) We found that 90% of women with CAIS in this study had sexual difficulties when compared with the general female population, most commonly sexual infrequency and vaginal penetration difficulty; 77% perceived their vagina as small, but on genital examination only 35% had vaginal hypoplasia. CONCLUSION(S) Androgen deficiency leads to sexual problems. Vaginal hypoplasia and negative psychological adaptation to living with an intersex condition are likely to have contributed to the high rates of sexual problems found in this study. Treatments for vaginal hypoplasia need to be evaluated with outcome studies of long-term sexual function, quality of life, and satisfaction. Clinical services for the management of intersex conditions need to be multidisciplinary and aim to optimize the patient's physical and psychological health.
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Affiliation(s)
- Catherine L Minto
- The Middlesex Clinic, Elizabeth Garrett Anderson Hospital, University College London Hospitals, London, United Kingdom
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36
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Abstract
We evaluated psychological outcomes and gender development in 22 women with complete androgen insensitivity syndrome (CAIS). Participants were recruited through a medical database (n = 10) or through a patient support group (n = 12). Controls included 14 males and 33 females, of whom 22 were matched to women with CAIS for age, race, and sex-of-rearing. Outcome measures included quality of life (self-esteem and psychological general well-being), gender-related psychological characteristics (gender identity, sexual orientation, and gender role behavior in childhood and adulthood), marital status, personality traits that show sex differences, and hand preferences. Women recruited through the database versus the support group did not differ systematically, and there were no statistically significant differences between the 22 women with CAIS and the matched controls for any psychological outcome. These findings argue against the need for two X chromosomes or ovaries to determine feminine-typical psychological development in humans and reinforce the important role of the androgen receptor in influencing masculine-typical psychological development. They also suggest that psychological outcomes in women with CAIS are similar to those in other women. However, additional attention to more detailed aspects of psychological well-being in CAIS is needed.
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Affiliation(s)
- Melissa Hines
- Department of Psychology, City University, London, England, United Kingdom.
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37
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Wisniewski AB, Migeon CJ. Long-term perspectives for 46,XY patients affected by complete androgen insensitivity syndrome or congenital micropenis. Semin Reprod Med 2002; 20:297-304. [PMID: 12428209 DOI: 10.1055/s-2002-35376] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Controversy concerning optimal treatment for individuals affected by syndromes of abnormal sex differentiation can best be resolved with knowledge about long-term medical, surgical, and psychosexual outcomes of patients. Follow-up information has recently been gathered on older cohorts of the following patient groups: (1) those affected by complete androgen insensitivity syndrome (CAIS) raised female and (2) those affected by congenital micropenis raised male or female. As a group, women with CAIS were satisfied with their female gender and sexual function. However, a need for better patient education was identified for this specific population. Most patients with congenital micropenis, whether raised male or female, were satisfied with their gender. Regardless of sex of rearing, dissatisfaction with the appearance and function of the genitalia as judged by both physicians and subjects was evident. For patients with congenital micropenis, male sex of rearing was concluded to be optimal because genital reconstructive surgery is not required with this choice.
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Affiliation(s)
- Amy B Wisniewski
- Department of Pediatrics, Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Park 211, Baltimore, MD 21287, USA
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38
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Abstract
The hypothesis that human male and female amative orientation, arousal and courtship are sex-hormone dependent had as its precursor John Hunter's recorded but unpublished 18th century experiments of cross-sexed gonadal transplants in chicks. The hypothesis gained momentum in the 20th century after the discovery and eventual marketing of the sex hormones, and after the experimental demonstration by William C. Young that, in guinea-pigs, cross-sexed hormone administered prenatally influenced their subsequent male/female courtship and mating behavior. Comparatively and in review, human clinical syndromes of hypermasculinization and hypomasculinization do not disconfirm the hormonal hypothesis, but they do not adequately confirm it, either. They are compatible with the idea of a cofactor that governs whether amative orientation in practice, ideation and imagery is homosexual, heterosexual or bisexual.
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Affiliation(s)
- John Money
- Johns Hopkins University and Hospital, Baltimore, MD, USA.
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39
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Slijper FM, Frets PG, Boehmer AL, Drop SL, Niermeijer MF. Androgen insensitivity syndrome (AIS): emotional reactions of parents and adult patients to the clinical diagnosis of AIS and its confirmation by androgen receptor gene mutation analysis. Horm Res 2000; 53:9-15. [PMID: 10965214 DOI: 10.1159/000023506] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The emotional reactions of parents and adult patients on disclosure of the clinical diagnosis of androgen insensitivity syndrome (AIS) and its later confirmation by gene mutation analysis were assessed. A semistructured interview and three questionnaires were used. Parents came from 18 different families with a total of 20 children (15 complete AIS, 5 partial AIS), 19 raised as girls, 1 as a boy. Ten adult women with complete AIS came from six families. The short-term reaction upon the clinical diagnosis was in the majority of both parents and adult patients associated with shock, grief, anger, and shame and in the mothers and adult patients with guilt. Emotional reactions were more long-lasting in mothers and adult patients than in fathers. The confirmation by DNA analysis did not alter the actual feelings of both parents. Adolescents with AIS should be informed completely - but in a step-by-step way - about their condition, since adult patients indicated that they had suffered from being not at all or misinformed about AIS in their adolescence.
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Affiliation(s)
- F M Slijper
- Department of Child and Adolescent Psychiatry, Sophia Children's Hospital and Erasmus University, Rotterdam, The Netherlands
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40
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Wisniewski AB, Migeon CJ, Meyer-Bahlburg HF, Gearhart JP, Berkovitz GD, Brown TR, Money J. Complete androgen insensitivity syndrome: long-term medical, surgical, and psychosexual outcome. J Clin Endocrinol Metab 2000; 85:2664-9. [PMID: 10946863 DOI: 10.1210/jcem.85.8.6742] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Controversy concerning the most appropriate treatment guidelines for intersex children currently exists. This is due to a lack of long-term information regarding medical, surgical, and psychosexual outcome in affected adults. We have assessed by questionnaire and medical examination the physical and psychosexual status of 14 women with documented complete androgen insensitivity syndrome (CAIS). We have also determined participant knowledge of CAIS as well as opinion of medical and surgical treatment. As a whole, secondary sexual development of these women was satisfactory, as judged by both participants and physicians. In general, most women were satisfied with their psychosexual development and sexual function. Factors reported to contribute to dissatisfaction were sexual abuse in one case and marked obesity in another. All of the women who participated were satisfied with having been raised as females, and none desired a gender reassignment. Although not perfect, the medical, surgical, and psychosexual outcomes for women with CAIS were satisfactory; however, specific ways for improving long-term treatment of this population were identified.
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Affiliation(s)
- A B Wisniewski
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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41
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Abstract
Animal models of gonadal hormone influences on the sexual differentiation of brain and behaviour are reviewed and discussed as a basis for predicting hormonal influences on human neurobehavioural development. Behavioural outcomes in clinical intersex cases, including congenital adrenal hyperplasia, androgen insensitivity syndrome, enzymatic deficiencies and situations in which hormones have been prescribed during pregnancy are reviewed. It is concluded that the prenatal or neonatal hormone environment contributes to the development of human behaviours that show sex differences, particularly childhood play behaviour, sexual orientation and core gender identity. There also is some evidence for influences on aggression and cognition. It is also concluded that additional research is needed to determine why some intersex patients assigned and reared as girls are not successful in this identity and role.
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Affiliation(s)
- M Hines
- Department of Psychology, City University, London, UK
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42
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Schwarz HP. Sex reassignment at birth. Arch Pediatr Adolesc Med 1997; 151:1064. [PMID: 9343026 DOI: 10.1001/archpedi.1997.02170470098026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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43
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Irwin KM. Sex, lies and androgen insensitivity syndrome. CMAJ 1996; 154:1833. [PMID: 8653640 PMCID: PMC1487730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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44
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Kemp BD. Sex, lies and androgen insensitivity syndrome. CMAJ 1996; 154:1829; author reply 1833. [PMID: 8653636 PMCID: PMC1487754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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45
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Tako HD. Sex, lies and androgen insensitivity syndrome. CMAJ 1996; 154:1832-3. [PMID: 8653639 PMCID: PMC1487747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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46
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Groveman SA. Sex, lies and androgen insensitivity syndrome. CMAJ 1996; 154:1829, 1832; author reply 1833. [PMID: 8653637 PMCID: PMC1487756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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47
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Sex, lies and androgen insensitivity syndrome. CMAJ 1996; 154. [PMID: 8653638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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48
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Natarajan A. Medical ethics and truth telling in the case of androgen insensitivity syndrome. CMAJ 1996; 154:568-70. [PMID: 8630847 PMCID: PMC1487631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Should a physician always tell the truth to a patient? Is biomedical ethics too "politically correct" in certain situations? The second-place winner in the 1995 Logie Medical Ethics Essay Contest discusses whether telling the truth is the proper course for a physician dealing with certain patients.
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49
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Abstract
This study investigated the relationship between alcoholics' personality characteristics [as indexed by the Eysenck Personality Questionnaire (EPQ)] and sex steroid levels. Three serum samples were drawn over a 90-min period in 58 inpatient male alcoholics (mean 33 days sober) and 33 non-alcoholic controls. The EPQ was administered at approximately the same point in the treatment process. Replicating previous work, we found alcoholics scored significantly higher on the Neuroticism and Psychoticism scales of the EPQ than controls. Alcoholics also had higher levels of estradiol and total testosterone than controls, which may be reflective of a biological rebound or characteristic premorbid levels. A significant positive correlation was found between testosterone and extroversion in controls, but not in alcoholics. Alcoholics showed a positive correlation between estradiol and neuroticism and a negative relationship between estradiol and extroversion. The results suggest that (a) 'normal' hormone-personality relationships are disrupted in male alcoholics, and b) personality and psychological changes consistent with the physical feminization syndrome may occur in male alcoholics.
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Affiliation(s)
- A C King
- University of Oklahoma Health Sciences Center, Department of Psychiatry and Behavioral Sciences, Oklahoma City 73104, USA
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50
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Ahlquist JA. Gender identity in testicular feminisation. Phenotypically, anatomically, legally, and socially female. BMJ 1994; 308:1041. [PMID: 8167526 PMCID: PMC2539896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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