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Malouf M, Inman A, Carr A, Franco J, Brooks L. Health-Related Quality of Life, Mental Health and Psychotherapeutic Considerations for Women Diagnosed with a Disorder of Sexual Development: Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-253465] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Frisén L, Nordenström A, Falhammar H, Filipsson H, Holmdahl G, Janson PO, Thorén M, Hagenfeldt K, Möller A, Nordenskjöld A. Gender role behavior, sexuality, and psychosocial adaptation in women with congenital adrenal hyperplasia due to CYP21A2 deficiency. J Clin Endocrinol Metab 2009; 94:3432-9. [PMID: 19567521 DOI: 10.1210/jc.2009-0636] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Gender-atypical behavior has been described in young girls as well as in women with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency. OBJECTIVE The aim of the study was to assess health-related, psychosexual, and psychosocial parameters and correlate the results to CYP21A2 genotype. DESIGN AND PARTICIPANTS Sixty-two Swedish women with CAH and age-matched controls completed a 120-item questionnaire and a validated quality of life instrument [psychological general well-being (PGWB) formula] to identify psychosexual and psychosocial parameters. The patients were divided into four CYP21A2 genotype groups. RESULTS The women with CAH held more male-dominant occupations (30%) compared to controls (13%) (P = 0.04), especially those in the null genotype group (55%) (P = 0.006). They also reported a greater interest in rough sports (74%) compared to controls (50%) (P = 0.007). Eight women with CAH (14%) reported a prime interest in motor vehicles, compared to none of the controls (P = 0.002). Non-heterosexual orientation was reported by 19% of women with CAH (P = 0.005), 50% in the null genotype group (P = 0.0001), 30% in I2 splice (NS), and 5% in I172N (NS). PGWB total score did not differ between patients and controls. CONCLUSION We identified increased gender-atypical behavior in women with CAH that could be correlated to the CYP21A2 genotype. This speaks in favor of dose-dependent effects of prenatal androgens on the development of higher brain functions. The impact of the disease on upbringing and interpersonal relationships did not correlate with disease severity, indicating that other factors, such as coping strategies, are important for psychosocial adaptation. This illustrates the need for psychological support to parents and patients.
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Affiliation(s)
- Louise Frisén
- Department of Psychiatry, Danderyd Hospital, SE-18287 Stockholm, Sweden.
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Schützmann K, Brinkmann L, Schacht M, Richter-Appelt H. Psychological distress, self-harming behavior, and suicidal tendencies in adults with disorders of sex development. ARCHIVES OF SEXUAL BEHAVIOR 2009; 38:16-33. [PMID: 17943433 DOI: 10.1007/s10508-007-9241-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 05/08/2007] [Accepted: 05/12/2007] [Indexed: 05/25/2023]
Abstract
Evaluation of psychological distress has received relatively little attention in research on persons with disorders of sex development (DSD). Results of previous studies varied considerably, but most studies did not find increased levels of psychological distress. We conducted a pilot study based on a sample of 37 persons with diverse forms of DSD recruited via various strategies. The Brief Symptom Inventory (BSI) was used to assess self-reported psychological distress. Psychological distress varied broadly across all diagnostic subgroups. Overall, the BSI Global Severity Index indicated higher distress in the sample of persons with DSD compared to a non-clinical norm population of women, with an effect size of d = 0.67. According to predefined BSI criteria, 59% of participants were classified as a clinical case. Self-harming behavior and suicidal tendencies were also assessed and compared to a community based sample of women, including subgroups of traumatized women with a history of physical or sexual abuse. The prevalence rates of self-harming behavior and suicidal tendencies in the DSD sample exceeded the rates of the non-traumatized comparison subgroup, with rates comparable to the traumatized comparison groups of women with physical or sexual abuse. As possible explanations for the higher distress found here compared to most previous studies, differences in measures and sample recruitment are discussed. Our results suggest that adults with DSD are markedly psychologically distressed with rates of suicidal tendencies and self-harming behavior on a level comparable to non-DSD women with a history of physical or sexual abuse, but sample recruitment procedures do not permit a firm generalization.
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Affiliation(s)
- Karsten Schützmann
- Institute for Sex Research and Forensic Psychiatry, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Hamburg, Germany
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Axelrad ME, Berg JS, Coker LA, Dietrich J, Adcock L, French SL, Gunn S, Ligon BL, McCullough LB, Sutton VR, Karaviti LP. The gender medicine team: "it takes a village". Adv Pediatr 2009; 56:145-64. [PMID: 19968947 DOI: 10.1016/j.yapd.2009.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Marni E Axelrad
- Pediatric Service, Texas Children's Hospital, Houston, TX 77030, USA.
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Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin North Am 2008; 92:1163-92, xi. [PMID: 18721657 DOI: 10.1016/j.mcna.2008.04.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Infertility in women has many possible causes and must be approached systematically. The most common cause of medically treatable infertility is the polycystic ovary syndrome (PCOS). This syndrome is common in young women and is the cause of anovulatory infertility in 70% of cases. It is therefore an important condition to screen and manage in primary care medical settings. In the past 10 years, insulin sensitization with weight loss or metformin has been shown to be a safe and effective treatment for PCOS infertility that eliminates the risk of multiple pregnancy and may reduce the risk of early pregnancy loss as compared with ovulation-inductor drugs. The authors believe metformin should be considered as first-line therapy because it has the advantage to allow for normal single ovulation, for reduced early pregnancy loss, and, most importantly, lifestyle modifications and weight loss before pregnancy. Losing weight not only improves fertility but also reduces adverse pregnancy outcomes associated with obesity.
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Affiliation(s)
- Maryse Brassard
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, 3001, 12th North Avenue, Sherbrooke, QC J1H 5N4, Canada
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Ning C, Green-Golan L, Stratakis CA, Leschek E, Sinaii N, Schroth E, Ernst M, Merke DP. Body image in adolescents with disorders of steroidogenesis. J Pediatr Endocrinol Metab 2008; 21:771-80. [PMID: 18825877 PMCID: PMC3132103 DOI: 10.1515/jpem.2008.21.8.771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM Little is known about body image in children with endocrine conditions. We evaluated body image in children with congenital adrenal hyperplasia (CAH), familial male precocious puberty (FMPP), and Cushing's syndrome (CS). STUDY DESIGN We compared 67 patients (41 CAH, 12 FMPP, 14 CS) age 8-18 years with 55 age-matched controls. RESULTS Patients expressed more weight unhappiness than controls (females: p < 0.001; males: p = 0.01). This difference remained for females after adjusting for body mass index (BMI) (p = 0.03), but not for males (p = 0.12). Unhappiness with height and age of appearance was similar between groups. In female patients, higher BMI was a significant predictor of weight unhappiness (p = 0.01). CONCLUSION Adolescents with CAH, FMPP, and CS are at risk for negative body image regarding weight, but not height or age of appearance. Weight unhappiness is partially related to greater weight, but factors unrelated to physical findings seem to contribute to negative body image in female patients.
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Affiliation(s)
- Cong Ning
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Wünsch L, Wessel L. Chirurgische Strategien bei Störungen der Geschlechtsentwicklung. Monatsschr Kinderheilkd 2008. [DOI: 10.1007/s00112-008-1675-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Merke DP. Approach to the adult with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 2008; 93:653-60. [PMID: 18326005 PMCID: PMC2266964 DOI: 10.1210/jc.2007-2417] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders where there is impairment of cortisol biosynthesis. CAH due to 21-hydroxylase deficiency accounts for 95% of cases and shows a wide range of clinical severity. Treatment of the classic or severe form of CAH is targeted at replacing cortisol and aldosterone and effectively controlling excess androgen symptoms by using the lowest possible glucocorticoid dose. Treatment of the mild or nonclassic form is targeted at controlling excess androgen symptoms and may or may not involve glucocorticoid therapy. Hydrocortisone is the treatment of choice for children, but there is no consensus on how patients should be treated as adults. Current glucocorticoid therapy is suboptimal because it is often difficult to reduce excess androgen without giving excess glucocorticoid, and patients may experience hypercortisolism, androgen excess, or a combination of these states. Treatment of CAH, especially in the adult patient, remains controversial given the lack of prospective randomized controlled trials comparing treatment regimens. Nevertheless, patients benefit from careful individualized therapy with avoidance of Cushingoid side effects and optimization of reproductive, sexual, and bone health.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center, Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1932, USA.
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Meyer-Bahlburg HFL, Dolezal C, Baker SW, New MI. Sexual orientation in women with classical or non-classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. ARCHIVES OF SEXUAL BEHAVIOR 2008; 37:85-99. [PMID: 18157628 DOI: 10.1007/s10508-007-9265-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
46,XX individuals with classical congenital adrenal hyperplasia (CAH) due to deficiency of the enzyme, 21-hydroxylase, show variable degrees of masculinization of body and behavior due to excess adrenal androgen production. Increased bisexuality and homosexuality have also been reported. This article provides a review of existing reports of the latter and presents a new study aimed at replicating the previous findings with detailed assessments of sexual orientation on relatively large samples, and at extending the investigation to the mildest form, non-classical (NC) CAH. Also, this is the first study to relate sexual orientation to the specific molecular genotypes of CAH. In the present study, 40 salt-wasters (SW), 21 SV (simple-virilizing), 82 NC, and 24 non-CAH control women (sisters and female cousins of CAH women) were blindly administered the Sexual Behavior Assessment Schedule (SEBAS-A, 1983 ed.; H. F. L. Meyer-Bahlburg & A. A. Ehrhardt, Privately printed). Most women were heterosexual, but the rates of bisexual and homosexual orientation were increased above controls not only in women with classical CAH, but also in NC women, and correlated with the degree of prenatal androgenization. Classifying women by molecular genotypes did not further increase the correlation. Diverse aspects of sexual orientation were highly intercorrelated, and principal components analysis yielded one general factor. Bisexual/homosexual orientation was (modestly) correlated with global measures of masculinization of non-sexual behavior and predicted independently by the degree of both prenatal androgenization and masculinization of childhood behavior. We conclude that the findings support a sexual-differentiation perspective involving prenatal androgens on the development of sexual orientation.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute & Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA.
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Lang C, Kuhnle U. Intersexuality and alternative gender categories in non-Western cultures. HORMONE RESEARCH 2008; 69:240-50. [PMID: 18204272 DOI: 10.1159/000113025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Accepted: 04/25/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the Western world, it is widely accepted as natural - and seen almost as a law of nature - that mankind is divided into two sexes or genders - males and females. In many cultures and societies, however, more than two sex and/or gender categories are recognized, which in some instances refer to the biological sex and in others to gender roles and social status. AIMS To give an intercultural comparison of various ways of dealing with gender variance. METHODS In the following paper, we review the anthropological literature during the last 100 years describing individuals who live neither as men nor women in various non-Western cultures. RESULTS Only rarely, these individuals suffer from disorders of sex development in the modern medical or biological definition: in many if not all societies there have been individuals who are not covered by the gender category of male and female. CONCLUSION There thus appears to be a cultural need for people with a special neither-male-nor-female status, which might be classified as 'gender variance'.
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Affiliation(s)
- Claudia Lang
- Department for Anthropology and African Studies, Ludwig Maximilian University, Munich, Germany
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Gastaud F, Bouvattier C, Duranteau L, Brauner R, Thibaud E, Kutten F, Bougnères P. Impaired sexual and reproductive outcomes in women with classical forms of congenital adrenal hyperplasia. J Clin Endocrinol Metab 2007; 92:1391-6. [PMID: 17284631 DOI: 10.1210/jc.2006-1757] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The objectives of the study were 2-fold: 1) a detailed description of sexual and reproductive outcomes in adult women with congenital adrenal hyperplasia (CAH) of different phenotypic severity at birth; and 2) comparisons of these outcomes among CAH subtypes and between CAH women and non-CAH control women. DESIGN This was a cross-sectional study using a face-to-face interview, a written questionnaire, the Female Sexual Function Index, and a gynecological examination. PATIENTS Patients included 35 women with CAH, representing Prader stages I-V at birth, aged 18-43 yr, who had been treated from birth to adolescence in the same pediatric endocrine clinics. Sixty-nine non-CAH healthy control women were selected from hospital-staff families. RESULTS None of the CAH women expressed doubts about their gender assignment. Twenty percent (seven of 35) had homosexual inclinations; 23% (eight of 35) were married; three reported a complete lack of sexual activity; and 37% (13 of 35) said they never had heterosexual intercourse with vaginal penetration. Sexual functioning as assessed by the Female Sexual Function Index was much lower in CAH women than controls and lowest in CAH women with high Prader stages. Eighty-one percent (18 of 22) experienced pain during vaginal penetration. Only eight women became pregnant, and 17% (six of 35) had children. CONCLUSIONS Despite expert medical and surgical care by physicians dedicated to this rare disease, women with CAH still suffer major limitations in their sexual function and reproductive life.
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Affiliation(s)
- F Gastaud
- Centre de Référence des Maladies Rares de la Différenciation Sexuelle, Lyon-Paris, Department of Pediatric and Adult Endocrinology, Necker Hospital, Paris V University, France
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Johannsen TH, Ripa CPL, Mortensen EL, Main KM. Quality of life in 70 women with disorders of sex development. Eur J Endocrinol 2006; 155:877-85. [PMID: 17132758 DOI: 10.1530/eje.1.02294] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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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Julka S, Bhatia V, Singh U, Northam E, Dabadghao P, Phadke S, Wakhlu A, Warne GL. Quality of life and gender role behavior in disorders of sexual differentiation in India. J Pediatr Endocrinol Metab 2006; 19:879-88. [PMID: 16995567 DOI: 10.1515/jpem.2006.19.7.879] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Culture-specific tools to assess longterm psychosocial outcomes for patients with disorders of sexual differentiation are scant. We conducted a study to develop tools for evaluating gender role behavior and health related quality of life for Indian adolescent patients with intersex disorders. We also studied factors important to parents while deciding sex of rearing for their baby. METHODS A 29-item gender role behavior questionnaire and an 18-item health related quality-of-life questionnaire were administered to 82 healthy controls, 13 patients with intersex disorders and 18 patients with type 1 diabetes mellitus. Internal consistency was checked by Cronbach's alpha and test-retest reliability using intra-class correlation coefficient. Responses of 28 parents to a questionnaire on factors affecting the decision of sex of rearing were recorded on a 5-point Likert scale in order of importance. RESULTS Cronbach's alpha was 0.92 and 0.75, and intra-class correlation coefficient 0.76 and 0.75, for the gender role behavior and quality-of-life questionnaires respectively, indicating a high degree of internal consistency and stability. The mean composite scores for healthy girls on the gender role behavior questionnaire (82.5 +/- 8.7) differed significantly from that for healthy boys (53.2 +/- 7.1, p <0.001). Factors important to parents while making decisions for sex of rearing were appearance of the genitalia, medical advice, ability to bear children and economic independence. CONCLUSIONS We have created valid tools to study gender role behavior and quality of life in adolescent patients with intersex disorders in India. We have also identified in a quantitative way the factors of greatest importance to parents while deciding sex of rearing. These results have direct utility in the management of patients with intersex disorders in India and other similar cultures.
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Affiliation(s)
- S Julka
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Ogilvie CM, Crouch NS, Rumsby G, Creighton SM, Liao LM, Conway GS. Congenital adrenal hyperplasia in adults: a review of medical, surgical and psychological issues. Clin Endocrinol (Oxf) 2006; 64:2-11. [PMID: 16402922 DOI: 10.1111/j.1365-2265.2005.02410.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Our knowledge of the experience of adults with congenital adrenal hyperplasia (CAH) as they pass through life is only now emerging. In this review we gather medical, surgical and psychological literature pertaining to adults with CAH and consider this alongside practical experience gained from a dedicated adult CAH clinic. There is increasing awareness for the need for multidisciplinary teams who have knowledge of CAH particularly with respect to gynaecological surgery and clinical psychology for women and testicular function in men. Routine management of CAH comprises adjustment of glucocorticoid and mineralocorticoid treatment according to individual needs balancing biochemical markers, compliance and long term risks. Bone density is one such long term concern and is not greatly reduced in most individuals with CAH. More recently, attention has turned to cardiovascular risk factors and catecholamine deficiency in adults with CAH. Women with CAH require access to an experienced gynaecologist, specialised pregnancy care and psychosexual support. The very low fertility rates for women with CAH previously reported appear to be improving with time. Men with CAH are often lost to follow up and therefore miss out on surveillance for hypogonadism either through the effect of adrenal rests of from suppression of gonadotrophins resulting in a high prevalence of oligospermia.
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Lean WL, Deshpande A, Hutson J, Grover SR. Cosmetic and anatomic outcomes after feminizing surgery for ambiguous genitalia. J Pediatr Surg 2005; 40:1856-60. [PMID: 16338305 DOI: 10.1016/j.jpedsurg.2005.08.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reports on anatomic and cosmetic outcomes after genital surgery for children with ambiguous genitalia are mixed, with recent reports using standardized assessments suggesting poor outcomes and that multiple operations may be required. METHODS All children with ambiguous genitalia and who had feminizing surgery at the Royal Children's Hospital in Melbourne, Australia, were identified. Standardized genital assessment was undertaken at their clinical review after informed consent. Underlying diagnosis, number and type of procedures performed, and the expertise of the surgeon were recorded from their medical notes. RESULTS Of 32 patients examined aged 13 to 33 years, 47% had congenital adrenal hyperplasia. Ten patients had initial surgery performed elsewhere. Overall, there were good anatomic and cosmetic outcomes for those initially treated at our institute by a specialized surgeon, although some required additional intervention in adolescence or adulthood. Initial surgery before or after 2 years of age did not significantly affect outcomes. Those patients who had only 1 operation (by a surgeon with special interest in intersex) had better cosmetic and anatomic outcomes than those patients who had multiple operations. CONCLUSIONS Cosmetic and anatomic outcomes of surgery for ambiguous genitalia were generally good when undertaken by pediatric surgeons with specific expertise in intersex surgery.
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Affiliation(s)
- Wei Ling Lean
- Department of Surgery, Royal Children's Hospital, Melbourne 3052, Australia
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Warne G, Grover S, Hutson J, Sinclair A, Metcalfe S, Northam E, Freeman J. A long-term outcome study of intersex conditions. J Pediatr Endocrinol Metab 2005; 18:555-67. [PMID: 16042323 DOI: 10.1515/jpem.2005.18.6.555] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
CONTEXT Clinical management of intersex conditions is controversial because the available evidence is limited and conflicting, with no long-term population based studies comparing matched controls. OBJECTIVE To assess the long-term psychological, sexual and social outcomes of patients with intersex compared with two matched control populations. DESIGN, SETTING AND PARTICIPANTS Three different aged-matched (18-32 years) patient groups completed a self-administered questionnaire of established quality of life and well-being inventories measuring physical' health, psychological adjustment and sexuality, following a mail-out to all identified patients. The intersex group (n = 50) and the Hirschsprung disease, a congenital disorder, control group (n = 27), were patients who had attended the Royal Children's Hospital, a tertiary centre, for their clinical care. The insulin dependent diabetes mellitus control group was recruited from an adult tertiary hospital. The study was conducted at the hospital-based Murdoch Childrens Research Institute. MAIN OUTCOME MEASURES Psychological, sexual and social outcomes. RESULTS The intersex group did not differ from controls on physical or mental health, depression, state anxiety, neuroticism, psychoticism or stressful life events. Intersex participants were satisfied with their overall body appearance, although intersex males were less satisfied than controls with the size (p <0.05) and appearance (p <0.01) of their sex organs. The intersex group was less likely to experience orgasm (p <0.05), tended to experience more pain during intercourse (p = 0.06), had more difficulties with penetration (p <0.01) and were less likely to have sexual activity several times or more a week (p <0.05) than the combined control groups. Intersex participants did not differ from controls in level of sexual desire or enjoyment of sexual activities. CONCLUSIONS Most patients with intersex had positive psychosocial and psychosexual outcomes, although some problems were reported with sexual activity. These results overall suggest that a model of care including early genital surgery carried out at a centre of excellence with a multidisciplinary team can minimize long-term complication rates.
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Affiliation(s)
- Garry Warne
- Department of Endocrinology & Diabetes, The University of Melbourne, Melbourne, Australia.
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Warne GL, Grover S, Zajac JD. Hormonal therapies for individuals with intersex conditions: protocol for use. ACTA ACUST UNITED AC 2005; 4:19-29. [PMID: 15649098 DOI: 10.2165/00024677-200504010-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Hormonal therapy forms part of the treatment of every intersex condition. For some conditions, such as salt-wasting congenital adrenal hyperplasia, hormonal replacement therapy is life saving because hormones necessary for survival (cortisol and aldosterone) are replaced. In contrast, other hormones such as androgens or mineralocorticoids are secreted in excessive amounts in congenital adrenal hyperplasia due to an enzyme imbalance, and the role of hormonal therapy is to suppress the unwanted hormone excess by exerting negative feedback. For patients with one of the many causes of hypogonadism, sex hormone replacement therapy may be prescribed to stimulate sexual development: growth of a hypoplastic penis in a young boy, pubertal changes (male or female), psychosexual development, and adult sexual behavior. It has equally important and highly beneficial effects on bone mineral density. Hormonal therapy is also used to treat the unborn child. For the last 20 years, prenatal dexamethasone treatment administered to the pregnant woman has been used to prevent the development of ambiguous genitalia in females with 21-hydroxylase deficiency. Outcome studies show this treatment to be well tolerated and, in general, efficacious. Intersex conditions are, however, difficult to treat because they may intrinsically perturb complex aspects of the person's gender identity, gender-role behavior, sexual orientation, sexual functioning, and psychologic adjustment. Furthermore, decisions made about the sex of an infant by doctors and parents do not always turn out to be correct; the person may grow up feeling uncertain about his or her gender identity, or worse still, harbor a sense of outrage about their life and treatment experiences. Such a person will have definite views about hormonal therapy when the time comes and skillful counseling will be needed. A vigorous debate about ethical aspects of current medical practices relating to intersex conditions has been waged for the last 7 years between certain patient advocacy organizations and the medical profession, and is expected to continue for some time. The quality of the debate will be improved by evidence. The results of a number of long-term follow-up studies have been published, and more are expected. The published studies show mixed, but mainly encouraging, results.
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Affiliation(s)
- Garry L Warne
- Centre for Hormone Research, Royal Children's Hospital, Melbourne, Victoria, Australia.
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Thyen U, Richter-Appelt H, Wiesemann C, Holterhus PM, Hiort O. Deciding on Gender in Children with Intersex Conditions. ACTA ACUST UNITED AC 2005; 4:1-8. [PMID: 15649096 DOI: 10.2165/00024677-200504010-00001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Biologic factors such as genetic and hormonal influences contribute to gender identity, gender role behavior, and sexual orientation in humans, but this relationship is considerably modified by psychologic, social, and cultural factors. The recognition of biologically determined conditions leading to incongruity of genetically determined sex, somatic phenotype, and gender identity has led to growing interest in gender role development and gender identity in individuals with intersex conditions. Sex assignment of children with ambiguous genitalia remains a difficult decision for the families involved and subject to controversial discussion among professionals and self-help groups. Although systematic empirical data on outcomes of functioning and health-related quality of life are sparse, anecdotal evidence from case series and individual patients about their experiences in healthcare suggests traumatic experiences in some. This article reviews the earlier 'optimal gender policy' as well as the more recent 'full consent policy' and reviews published data on both surgical and psychosocial outcomes. The professional debate on deciding on sex assignment in children with intersex conditions is embedded in a much wider public discourse on gender as a social construction. Given that the empirical basis of our knowledge of the causes, treatment options, long-term outcomes, and patient preferences is insufficient, we suggest preliminary recommendations based on clinical experience, study of the literature, and interviews with affected individuals.
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Affiliation(s)
- Ute Thyen
- Department of Child and Adolescent Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, University of Lübeck, Lübeck, Germany
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70
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Zucker KJ, Bradley SJ, Oliver G, Blake J, Fleming S, Hood J. Self-reported sexual arousability in women with congenital adrenal hyperplasia. JOURNAL OF SEX & MARITAL THERAPY 2004; 30:343-355. [PMID: 15672602 DOI: 10.1080/00926230490465109] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
As part of a larger study of psychosexual development and sexual functioning in women with congenital adrenal hyperplasia (CAH), we assessed self-reported sexual arousability with the Sexual Arousability Inventory-Short Form (SAI-SF; Hoon & Chambless, 1998). Compared to their unaffected sisters/female cousins (n = 15), women with CAH (n = 30) reported significantly lower sexual arousability on the SAI, with an effect size, using Cohen's d, of 1.16. For both the CAH women alone and combined with the controls, higher self-reported sexual arousability was significantly associated with (a) relationship status (married or cohabitating with a man versus being single or not in a relationship); (b) higher levels of sexual attraction to men in fantasy in the past 12 months on the Erotic Response and Orientation Scale (Storms, 1980); (c) higher Kinsey interview ratings of a heterosexual orientation in behavior in the past 12 months; and (d) more sexual experiences with men, according to a modified version of the Zuckerman (1973) Heterosexual Experience Scale (HES), in the past 12 months and lifetime (all ps < .001-.05). CAH women who were simple virilizers (versus salt-wasters) and those assigned female at birth (versus delayed or male) tended to report higher levels of sexual arousability (p < .10). Self-reported degree of satisfaction with genital surgery and genital function was also associated with higher levels of arousability. For CAH women and both groups combined, multiple regression analysis showed that the sole predictor of self-reported sexual arousability was HES lifetime sexual experiences with men. We discuss the results in the context of assessing sexual function and dysfunction in women with CAH.
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Affiliation(s)
- Kenneth J Zucker
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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71
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Zaparackaite I, Barauskas V, Nielsen OH. Feminising surgery in male pseudohermaphrodites. Pediatr Surg Int 2004; 20:538-42. [PMID: 15221366 DOI: 10.1007/s00383-004-1209-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2004] [Indexed: 11/26/2022]
Abstract
In the framework of the international project between the paediatric surgery clinics of Kaunas Medical University and Copenhagen University Hospital, 34 patients raised as females were examined and treated. Eighteen patients were affected by androgen insensitivity syndrome, and 16 patients by mixed gonadal dysgenesis. All patients had a Y chromosome, although external genitalia was either typically female or had mixed features of both sexes. The particulars of diagnostics and treatment are discussed, focusing on surgical complications.
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Affiliation(s)
- Indre Zaparackaite
- Kaunas Medical University Hospital, Paediatric Surgery Department, Eiveniu 2, LT-3007, Lithuania.
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72
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Reiner WG. Psychosexual development in genetic males assigned female: the cloacal exstrophy experience. Child Adolesc Psychiatr Clin N Am 2004; 13:657-74, ix. [PMID: 15183379 DOI: 10.1016/j.chc.2004.02.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Genetic males who have cloacal exstrophy, a rare, severe pelvic field defect that leads to aphallia, traditionally have been socially, legally, and surgically sex-assigned female at birth and reared female, despite a male karyotype and a typical male prenatal hormonal milieu. Psychosexual development in such children previously has been unknown. Studies of 29 children revealed that despite the absence of the typical postnatal and pubertal androgen surges and the presence of female genitalia, all female-assigned subjects displayed a marked male-typical shift in psychosocial and psychosexual development. Nearly half of them have declared themselves male. Psychosexual development, including gender identity, in genetic and hormonal male neonates seems to be influenced heavily by prenatal androgen exposure. The clinical practice of surgical sex assignment at birth requires re-evaluation.
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Affiliation(s)
- William G Reiner
- Departments of Urology and Psychiatry, University of Oklahoma Health Sciences Center, 920 S.L. Young Boulevard, Oklahoma City, OK 73104, USA.
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73
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Abstract
Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a disease with a varying phenotype depending on the mutation(s) present and the severity of the disease. All children with CAH need to be continuously cared for from birth or early infancy by specialists in paediatric endocrinology and surgery. Complications due to over- or under-treatment with corticosteroids are often seen during adolescence, and these problems often continue into adulthood. For the young woman with CAH, questions about menstruation, sexuality, fertility and the possible necessity of complementary surgery are always important issues that need to be discussed. To meet the needs of the young woman with CAH, it is important that the transition from paediatric to adult care be a process of parallel consultations over several years, always involving an experienced gynaecologic endocrinologist.
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Affiliation(s)
- Kerstin B Hagenfeldt
- Division of Obstetrics and Gynaecology, Department of Woman and Child Health, Karolinska Hospital, S 171 76 Stockholm, Sweden.
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74
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Berenbaum SA, Korman Bryk K, Duck SC, Resnick SM. Psychological adjustment in children and adults with congenital adrenal hyperplasia. J Pediatr 2004; 144:741-6. [PMID: 15192620 DOI: 10.1016/j.jpeds.2004.03.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine psychological health in individuals with one form of intersexuality, congenital adrenal hyperplasia (CAH), and its relation to characteristics of the disease and treatment. STUDY DESIGN Participants (ages 3-31 years) included 72 females and 42 males with CAH, and unaffected relatives (44 females and 69 males). Psychological adjustment was assessed with parent-reports on the Child Behavior Checklist (CBCL) and subject self-reports on the Self-Image Questionnaire for Young Adolescents (SIQYA) or the Multidimensional Personality Questionnaire (MPQ). Information about disease characteristics and genital surgery was obtained from medical records. RESULTS There were no significant differences between females with CAH and unaffected females on any measure. Psychological adjustment was not significantly associated with genital virilization or age at genital surgery. Males with CAH were not significantly different from unaffected males in childhood, but they showed more negative affect at older ages. CONCLUSIONS Psychological adjustment is not compromised in females with virilized genitalia who are treated early in life and reared as females. Adjustment does not appear to depend on the characteristics of the disease or its treatment, but sample size and restricted range limit generalizability about adjustment-disease associations.
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Affiliation(s)
- Sheri A Berenbaum
- Department of Psychology and Pediatrics, The Pennsylvania State University, University Park, Pennsylvania 16802, USA.
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75
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Labarta J, Bello E, Ferrández A, Mayayo E. Hiperplasia suprarrenal congénita: diagnóstico, tratamiento y evolución a largo plazo. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1575-0922(04)74628-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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76
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Stikkelbroeck NMML, Beerendonk CCM, Willemsen WNP, Schreuders-Bais CA, Feitz WFJ, Rieu PNMA, Hermus ARMM, Otten BJ. The long term outcome of feminizing genital surgery for congenital adrenal hyperplasia: anatomical, functional and cosmetic outcomes, psychosexual development, and satisfaction in adult female patients. J Pediatr Adolesc Gynecol 2003; 16:289-96. [PMID: 14597017 DOI: 10.1016/s1083-3188(03)00155-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are only a few reports analyzing the long term outcome of feminizing surgery in females with congenital adrenal hyperplasia (CAH). Such analysis is crucial to evaluate the treatment and to make necessary adjustments. STUDY OBJECTIVES To evaluate the adult outcome after feminizing surgery in adult females with salt wasting CAH. DESIGN Retrospective observational followup investigation. SETTING Outpatient clinic of a University Medical Center, in 2002. PARTICIPANTS Eight patients (born 1973-1983) who underwent feminizing surgery in infancy by the same procedure and the same pediatric surgeon in our center, and 19 healthy female controls (for visual analog scales). METHODS (a) Study of patients' records (n=8); (b) Systematic evaluation of the current situation (n=6): uroflowmetry, a written questionnaire to screen for psychopathology (Youth Adult Self Report, YASR), structured gynecologic examination and a structured psychosexual interview, including scoring on visual analog scales. RESULTS (a) The first surgery (age 0.1-3.7 yr) consisted of clitoris reduction and vaginoplasty (single-stage) in 7 patients and clitoris reduction only in one patient. The latter patient had vaginoplasty in puberty. In puberty, 6 of the 7 patients with an initial single-stage procedure required re-vaginoplasty. All 6 patients who participated in this systematic evaluation had undergone (re-) vaginoplasty in puberty; (b) 2 of the 6 patients experienced some urinary incontinence, and in one of them, the uroflowmetry result was abnormal. The YASR showed no psychopathology, except for 1 patient with a slightly elevated externalizing score. Gynecologic examination (n=5) revealed vaginal strictures in 3 patients (1 severe, 2 mild). The 2 patients without vaginal strictures had coitus regularly. In the interview, 2 patients called themselves bisexual, the other 4 heterosexual. None of the patients had homosexual contacts. Sexual developmental milestones (romantic interest, falling in love, kissing and petting, coitus) had been reached by all, except for 1 patient who did not have coitus yet. In the patient group, satisfaction with height, body hair, and external genitalia and sexual fantasies and interest, measured with visual analog scales, was not different compared to the control group, except for satisfaction with total body appearance, which was significantly lower in the patients. CONCLUSION Despite the poor outcome of the initial single-stage surgery in infancy and the inevitable re-operation in puberty, the adult outcome in our study population seems more positive than the findings in the few previous reports, especially with respect to sexual development and activity.
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Affiliation(s)
- Nike M M L Stikkelbroeck
- Departments of Pediatric Endocrinology, University Medical Center Nijmegen, Nijmegen, The Netherlands
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77
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Abstract
Infertility can be frustrating for patients and physicians. Endocrine dysfunction can impair fertility and alter pregnancy outcome. Once the diagnosis is secured, most endocrine disorders are reversible or can be adequately managed to restore fertility and decrease associated pregnancy complications. Improved understanding of the subtleties and intricacies of mechanisms by which endocrinopathies can hinder fertility and influence the course of a pregnancy is vital, more so in the era of assisted reproductive technology, because pregnancy in an abnormal endocrine environment can be disastrous. The role of autoimmunity in infertility and pregnancy loss is less clear; in this context, there are limited management options to improve fertility and overall pregnancy outcomes.
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Affiliation(s)
- Brinda N Kalro
- Division of Reproductive Endocrinology, Department of Obstetrics, University of Pittsburgh School of Medicine, Magee-Women's Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA.
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78
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Meyer-Bahlburg HFL. Gender assignment and reassignment in intersexuality: controversies, data, and guidelines for research. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 511:199-223. [PMID: 12575763 DOI: 10.1007/978-1-4615-0621-8_12] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University, New York, NY, USA
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79
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80
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Stikkelbroeck NMML, Hermus ARMM, Braat DDM, Otten BJ. Fertility in women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Obstet Gynecol Surv 2003; 58:275-84. [PMID: 12665708 DOI: 10.1097/01.ogx.0000062966.93819.5b] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED Fertility in women with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency appears to be reduced. The purpose of this review is to summarize the reported evidence about subfertility in women with CAH and to review the causes of reduced fertility. Compared with a non-CAH female population, pregnancy and live-birth rates are severely reduced in salt-wasting patients, mildly reduced in simple virilizing patients, and normal in nonclassical patients. Several factors have been suggested to contribute to the impaired fertility in CAH females: adrenal overproduction of androgens and progestins (17-hydroxyprogesterone and progesterone), ovarian hyperandrogenism, polycystic ovary syndrome, ovarian adrenal rest tumors, neuroendocrine factors, genital surgery, and psychological factors such as delayed psychosexual development, reduced sexual activity and low maternal feelings. It is obvious that these factors are interrelated. Improving endocrine, surgical, and psychological management could contribute to improving fertility chances in these patients. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to define the various types of CAH, to describe the fertility issues in the CAH patients, to outline the various other causes of hyperandrogenism, and to list the treatment options for the patient with CAH.
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Affiliation(s)
- Nike M M L Stikkelbroeck
- Department of Pediatric Endocrinology, University Medical Center Nijmegen, Nijmegen, The Netherlands
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81
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White PC, Speiser PW. Long-term consequences of childhood-onset congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2002; 16:273-88. [PMID: 12064893 DOI: 10.1053/beem.2002.0198] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a general term applied to several diseases caused by inherited defects of cortisol synthesis. The most common of these is steroid 21-mono-oxygenase (also termed 21-hydroxylase) deficiency (CAH-21OHD), found in approximately 1:10 000-1:15 000 live births. Potentially lethal adrenal insufficiency is characteristic of about two-thirds to three-quarters of patients with the classic salt-wasting form of CAH-21OHD. Non-salt-wasting forms of CAH-21OHD may be diagnosed based in part on genital ambiguity in affected newborn females, and/or by later evidence of androgen excess in members of either sex. Non-classical CAH-21OHD may be detected in up to 1-3% of certain populations, and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This chapter addresses issues relating to long-term consequences in adult life of CAH-21OHD diagnosed in early childhood or adolescence.
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Affiliation(s)
- Perrin C White
- Division of Pediatric Endocrinology and Professor of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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82
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SCHOBER JUSTINEM, CARMICHAEL POLLYA, HINES MELISSA, RANSLEY PHILIPG. THE ULTIMATE CHALLENGE OF CLOACAL EXSTROPHY. J Urol 2002. [DOI: 10.1016/s0022-5347(05)65455-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- JUSTINE M. SCHOBER
- From the Department of Psychology, City University, London, United Kingdom, and Hamot Medical Center, Erie, Pennsylvania
| | - POLLY A. CARMICHAEL
- From the Department of Psychology, City University, London, United Kingdom, and Hamot Medical Center, Erie, Pennsylvania
| | - MELISSA HINES
- From the Department of Psychology, City University, London, United Kingdom, and Hamot Medical Center, Erie, Pennsylvania
| | - PHILIP G. RANSLEY
- From the Department of Psychology, City University, London, United Kingdom, and Hamot Medical Center, Erie, Pennsylvania
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83
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84
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Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders caused by inborn errors of steroid metabolism. The most common form owing to 21-hydroxylase deficiency (CAH-21OHD) is present in about 1:10,000- 1:15,000 live births worldwide. In its classic salt-wasting form (-66-75% of cases) patients may suffer potentially lethal adrenal insufficiency. Non-salt-wasting forms of CAH-21 OHD are recognized by genital ambiguity in affected females, and by signs of androgen excess in later childhood in males. Non-classic CAH-21 OHD may be detected in up to 1-3% of certain populations, and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This chapter will address issues relating to transition of CAH care from the pediatric to the adult endocrinologist.
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Affiliation(s)
- P W Speiser
- Division of Pediatric Endocrinology, North Shore-Long Island Jewish Health System, New York, USA.
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85
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Aaronson IA. The investigation and management of the infant with ambiguous genitalia: a surgeon's perspective. CURRENT PROBLEMS IN PEDIATRICS 2001; 31:168-94. [PMID: 11436003 DOI: 10.1067/mps.2001.116127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- I A Aaronson
- Departments of Urology and Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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86
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Abstract
PURPOSE Sexual preference and adjustment of intersexuals have rarely been investigated. Interview techniques were used to explore these issues. MATERIALS AND METHODS Ten adult intersexuals (average age 34.2 years) were randomly selected from Intersex Society of North America members. Of the 10 subjects 8 had initially been gender assigned as female and 2 as male. A structured telephone interview was used to assess sexual orientation, sexual activity and satisfaction with gender assignment. RESULTS Sexual debut occurred at age 18.1 years (range 15 to 22). At debut, 4 females and 2 males engaged in heterosexual intercourse, and 4 females engaged in gynephilic (female) sexual contact. Despite female gender assignment of 8 and initial heterosexual activity by 4 subjects, the final choice of a sexual partner was female in all 8. Both males had initial heterosexual contact but only 1 continued to prefer female partners. Current number of sexual partners averaged 0.9 (range 0 to 2) and total number of sexual partners ranged from 1 to 300. Currently, 9 subjects are in a committed sexual relationship and 8 are able to achieve orgasm. Of the subjects 8 preferred being identified as intersexual, 1 male as male and 1 female as female. Two intersexuals with initial female gender assignment were undergoing male reassignment. CONCLUSIONS Most intersexuals preferred being identified as intersexual and had female partners. Most reported being satisfied with overall physical appearance but satisfaction with genitalia was highly variable. Based on these results, further study of a larger population is warranted.
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Affiliation(s)
- J M Schober
- Hamot Medical Center, Erie, Pennsylvania, USA
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87
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Schober JM. Sexual behaviors, sexual orientation and gender identity in adult intersexuals: a pilot study. J Urol 2001; 165:2350-3. [PMID: 11371976 DOI: 10.1016/s0022-5347(05)66201-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Sexual preference and adjustment of intersexuals have rarely been investigated. Interview techniques were used to explore these issues. MATERIALS AND METHODS Ten adult intersexuals (average age 34.2 years) were randomly selected from Intersex Society of North America members. Of the 10 subjects 8 had initially been gender assigned as female and 2 as male. A structured telephone interview was used to assess sexual orientation, sexual activity and satisfaction with gender assignment. RESULTS Sexual debut occurred at age 18.1 years (range 15 to 22). At debut, 4 females and 2 males engaged in heterosexual intercourse, and 4 females engaged in gynephilic (female) sexual contact. Despite female gender assignment of 8 and initial heterosexual activity by 4 subjects, the final choice of a sexual partner was female in all 8. Both males had initial heterosexual contact but only 1 continued to prefer female partners. Current number of sexual partners averaged 0.9 (range 0 to 2) and total number of sexual partners ranged from 1 to 300. Currently, 9 subjects are in a committed sexual relationship and 8 are able to achieve orgasm. Of the subjects 8 preferred being identified as intersexual, 1 male as male and 1 female as female. Two intersexuals with initial female gender assignment were undergoing male reassignment. CONCLUSIONS Most intersexuals preferred being identified as intersexual and had female partners. Most reported being satisfied with overall physical appearance but satisfaction with genitalia was highly variable. Based on these results, further study of a larger population is warranted.
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Affiliation(s)
- J M Schober
- Hamot Medical Center, Erie, Pennsylvania, USA
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88
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Meyer-Bahlburg HF. Gender and sexuality in classic congenital adrenal hyperplasia. Endocrinol Metab Clin North Am 2001; 30:155-71, viii. [PMID: 11344934 DOI: 10.1016/s0889-8529(08)70024-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The current debate about the psychosocial management of intersex patients has significant implications for 46,XX patients with classic congenital adrenal hyperplasia (CAH) in two respects: (1) the question of genital surgery for reasons other than purely medical ones before the patient is old enough to give informed consent, and (2) the question of gender assignment in severely masculinized patients. This article reviews the status of the empirical evidence for the development of gender and sexuality in 46,XX persons with classic CAH and its implications for clinical practice.
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Affiliation(s)
- H F Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, New York, New York, USA.
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89
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Lo JC, Grumbach MM. Pregnancy outcomes in women with congenital virilizing adrenal hyperplasia. Endocrinol Metab Clin North Am 2001; 30:207-29. [PMID: 11344937 DOI: 10.1016/s0889-8529(08)70027-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although low fertility rates have traditionally been reported among women with classic CAH and especially among women with the salt-wasting variant, more recent data suggest that fertility rates are significantly improved, largely owing to earlier treatment of CAH, improved compliance with therapy, and surgical advances in genital reconstruction. Furthermore, ovulation induction and assisted reproductive techniques are now available to women who remain infertile despite effective adrenal androgen suppression. Although the pregnancy experience in women with classic CAH remains limited, it is apparent that, once pregnant, these women have a high probability of successful outcome. Key issues should be emphasized in the management of CAH during gestation, including the need for assessing adrenal steroid replacement and adrenal androgen suppression, particularly in light of the interplay between maternal hyperandrogenism and the protective effect of placental aromatase activity, which provides a relatively large margin of safety for the female fetus. Maternal hormone levels should be evaluated in the context of laboratory-specific reference ranges for pregnancy. The infant should be examined for ambiguous genitalia and monitored for evidence of adrenal insufficiency. Although an affected female infant with classic CAH has not been reported as a pregnancy outcome of a mother with classic virilizing CAH, these concerns should be discussed during preconception counseling. Patients should also be aware of the importance of medication compliance and careful hormonal monitoring during the entire pregnancy. In most cases, successful gestational management requires the close coordination of care between the obstetrician and endocrinologist.
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Affiliation(s)
- J C Lo
- Department of Medicine, University of California, San Francisco, USA
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90
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Krege S, Walz KH, Hauffa BP, Körner I, Rübben H. Long-term follow-up of female patients with congenital adrenal hyperplasia from 21-hydroxylase deficiency, with special emphasis on the results of vaginoplasty. BJU Int 2000; 86:253-8; discussion 258-9. [PMID: 10930925 DOI: 10.1046/j.1464-410x.2000.00789.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess, in a long-term follow-up, female patients with congenital adrenal hyperplasia (CAH), with special emphasis on vaginal functional outcome and sexual activity after vaginoplasty. PATIENTS AND METHODS Twenty-seven patients with CAH (aged 14-33 years; six Prader grade II, 14 grade III, six grade IV and one grade V) underwent surgery between 1972 and 1988. Three of the patients underwent clitoridectomy, 24 clitoroplasty and 25 vaginoplasty (24 with a Fortunoff flap and one a 'pull-through' procedure). In 20 patients the vaginoplasty was a one-stage procedure, undertaken at a mean (range) age of 3.6 (1-9) years, and in five patients a two-stage operation. The analysis was based on the patients' history and examination; the patients also completed a questionnaire, including a psychological profile. RESULTS Nine of the 25 patients (36%) who underwent vaginoplasty developed intravaginal stenosis; of these nine, six were Prader grade III and three grade IV. All had undergone a single-stage procedure at a mean (range) age of 4.7 (2-9) years. Of the 16 patients who answered the questionnaire, 14 had problems with their overall body image; patients in whom vaginal stenosis was corrected were particularly anxious about sexual intercourse and had problems with orgasm. CONCLUSION The main problem during the long-term follow-up was intravaginal stenosis; all the affected patients had undergone a single-stage procedure early in life to correct ambiguous genitalia. This high rate of vaginal stenosis suggests that vaginoplasty should be undertaken at the beginning of puberty, because higher oestrogen levels may prevent stenosis and, if necessary, dilatation can be performed by the patient. These data also underscore the importance of psychological support in the treatment of children with CAH.
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Affiliation(s)
- S Krege
- Clinics of Urology, Gynaecology and Obstetrics, and Paediatric Endocrinology, University of Essen Medical School, Essen, Germany
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91
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Vates TS, Fleming P, Leleszi JP, Barthold JS, González R, Perlmutter AD. Functional, social and psychosexual adjustment after vaginal reconstruction. J Urol 1999; 162:182-7. [PMID: 10379784 DOI: 10.1097/00005392-199907000-00065] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction. MATERIALS AND METHODS We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women. RESULTS Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career. CONCLUSIONS While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.
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Affiliation(s)
- T S Vates
- Department of Pediatric Urology, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, USA
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93
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Affiliation(s)
- H F Meyer-Bahlburg
- New York State Psychiatric Institute, and Department of Psychiatry, Columbia University, New York 10032-2695, USA
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ALIZAI N, THOMAS D, LILFORD R, BATCHELOR A, JOHNSON N. FEMINIZING GENITOPLASTY FOR CONGENITAL ADRENAL HYPERPLASIA: WHAT HAPPENS AT PUBERTY? J Urol 1999. [DOI: 10.1016/s0022-5347(05)68986-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Meyer-Bahlburg HF. Health-related quality of life in intersexuality. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1999; 88:114-5. [PMID: 10102068 DOI: 10.1111/j.1651-2227.1999.tb14367.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Standardized methods for the assessment of health-related quality of life in patients with intersexuality are yet to be developed. This paper makes recommendations as to the kind of measures that should be included.
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Affiliation(s)
- H F Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, New York, USA
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97
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Schober JM. A Surgeon’s Response to the Intersex Controversy. THE JOURNAL OF CLINICAL ETHICS 1998. [DOI: 10.1086/jce199809408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
In congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, affected girls are born with ambiguous genitalia due to increased secretion of androgens in utero by the defective adrenal gland. Even though it is generally accepted that there are differences between male and female brain development, determining factors have been difficult to identify. Girls with CAH have frequently been studied to evaluate the impact of prenatal androgen exposure on psychological, psychosocial, and psychosexual development, and impairments in various areas have been identified. However, there is no comprehensive study available regarding the outcome of this chronic disorder in adult life. We studied the quality of life in women with CAH, with particular emphasis on how they cope with genital malformations, genital operations, and chronic disease as well as lifelong medication. The patients filled out questionnaires covering their physical state, psychological well-being, social relationships, and functional capacity, as well as questionnaires on psychosexual identification and psychosocial integration. The results were evaluated using a computerized statistical program for social studies. Out of a total of 94 patients above 18 years of age, 45 agreed to participate and were compared to 46 healthy, age-matched controls. Age at diagnosis was 2. 31 +/- 1.55 years and 38% suffered from the simple-virilizing, 45% from the salt-wasting, and 17.0% from the late-onset form of CAH. About one-third of patients had Prader stage 3 or 4 genital virilization. While the overall quality of life did not differ significantly, CAH patients were more often single (47.8% vs. 66.7%) and fewer of them had children (22.2% vs. 38.6%) compared to controls. Significant impairments were found in regard to body image and attitudes toward sexuality, but there was no increased homosexual preference. The women were successful in adjusting to illness and receiving social support. It is speculated that improved psychosocial adaptation is part of a coping mechanism that helps to maintain a high level of well-being despite impairment. Coping mechanisms should be identified and strengthened in order to help patients cope with their chronic illness.
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Affiliation(s)
- U Kuhnle
- Children's Hospital, University of Munich, Lindwurmstrasse 4 D-80337 Munich, Germany
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van der Kamp HJ, Slijper FM. The quality of life in adult female patients with congenital adrenal hyperplasia: a comprehensive study of the impact of genital malformations and chronic disease on female patients life. Eur J Pediatr 1996; 155:620-1. [PMID: 8831091 DOI: 10.1007/bf01957920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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