How sexually dimorphic are we? Review and synthesis

Gender Role, Gender Identity and Sexual Orientation in CAIS ("XY-Women") Compared With Subfertile and Infertile 46,XX Women

The perception of gender development of individuals with complete androgen insensitivity syndrome (CAIS) as unambiguously female has recently been challenged in both qualitative data and case reports of male gender identity. The aim of the mixed-method study presented was to examine the self-perception of CAIS individuals regarding different aspects of gender and to identify commonalities and differences in comparison with subfertile and infertile XX-chromosomal women with diagnoses of Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) and polycystic ovary syndrome (PCOS). The study sample comprised 11 participants with CAIS, 49 with MRKHS, and 55 with PCOS. Gender identity was assessed by means of a multidimensional instrument, which showed significant differences between the CAIS group and the XX-chromosomal women. Other-than-female gender roles and neither-female-nor-male sexes/genders were reported only by individuals with CAIS. The percentage with a not exclusively androphile sexual orientation was unexceptionally high in the CAIS group compared to the prevalence in "normative" women and the clinical groups. The findings support the assumption made by Meyer-Bahlburg ( 2010 ) that gender outcome in people with CAIS is more variable than generally stated. Parents and professionals should thus be open to courses of gender development other than typically female in individuals with CAIS.

The investigation of quality of life in 87 Chinese patients with disorders of sex development

Objective. In the process of care for disorders of sex development (DSD), clinical decisions should focus on the long-term quality of life (QOL). We sought to investigate the QOL of patients with DSD in China. Design. Case-control study was carried out. Patients. 90 patients of DSD participated in the study. Finally, 87 patients were analyzed including Turner's syndrome (23), Noonan syndrome (2), androgen insensitivity syndrome (22), testicular regression syndrome (2), congenital adrenal hyperplasia (16), and pure gonadal dysgenesis (22). Measurements. The WHOQOL-BREF questionnaire was chosen for the present investigation. Four domain scores were analyzed independently including physical, psychological, and social relationship and environmental domains. Results. The average age of the DSD group is 22.34 ± 4.97 years, and only 13.79% patients ever had sexual life. The scores of psychological and environmental domains were lower than that of the physical and social relationship domains, but the difference was not significant (P > 0.05). Compared with the Chinese urban population, the QOL scores of DSD patients in China were not significantly lower. Conclusions. With proper treatment, including the follow-up and psychological support, the QOL of DSD patients cannot be significantly reduced. For DSD patients, more attention should be paid to the potential psychological and sexual problems.

Ovotesticular disorder of sex development with unusual karyotype: patient report

BACKGROUND

Ovotesticular disorder of sex development (OT-DSD) (true hermaphroditism) is an anatomopathological diagnosis based on the findings of testicular and ovarian tissues in the same subject, in the same gonad (ovotestis), or in separate gonads. OT-DSD is a rare cause of sex ambiguity, and the most common karyotype is 46,XX; mosaics and chimeras are found only in 10%-20%.

AIM

To report a case of an OT-DSD patient with a rare karyotype constitution.

CASE REPORT

A 2-month-old child with male sex assignment was referred to our clinic for investigation of sex ambiguity. He was the second child of healthy unrelated parents; pregnancy and labor were uneventful. On physical examination, he had a 2.3-cm phallus and perineal hypospadias (Prader grade III); the right gonad was in the labioscrotal fold and the left was found in the inguinal channel. Karyotype was 46,XX/47,XXY/48,XXYY. Anatomopathological examination of gonads revealed right testis and left ovotestis. The male sex assignment was maintained; the child underwent left gonadectomy, removal of Mullerian structures and urethroplasty.

CONCLUSION

A thorough revision of literature revealed a single case of OT-DSD with the same chromosome constitution. Gonadal biopsy is necessary to establish diagnosis in cases of sex chromosome mosaicism.

Chromosomal Study is Must for Prepubertal Girl with Inguinal Hernia: Opportunity to Diagnose Complete Androgen Insensitivity Syndrome

The sufferers of complete androgen insensitivity syndrome (CAIS) are phenotypic females despite of having functional testes and normal male karyotype. They usually present late with primary amenorrhea but delayed diagnosis increases chance of gonadal malignancy. Alertness for this entity is crucial as with early diagnosis such disorder can be managed more appropriately for a better future. We hereby describe a case of CAIS in an 8-year-old girl presented with bilateral inguinal swellings. Endocrinological analysis, radiological investigations and cytogenetic studies were done. Investigations revealed absence of female internal genitalia. Karyotyping and molecular study confirmed the presence of Y chromosome. Parents were counseled regarding timely gonadectomy, fertility and other long term social issues.

Untying the gordian knot: what we do and don't know about gender-specific medicine-keynote address for the 2014 Academic Emergency Medicine Consensus Conference

Over the past two decades, a burgeoning interest in women's health, the direct consequence of the feminist movement, has inspired a worldwide interest in the differences between the normal function of men and women and their unique experiences of the same illnesses. The scope and significance of what we have discovered and continue to find has fundamentally changed the way we prevent, diagnose, and treat diseases. Important questions remain, however, and deserve specific investigation and analysis.

Regulation of male sex determination: genital ridge formation and Sry activation in mice

Sex determination is essential for the sexual reproduction to generate the next generation by the formation of functional male or female gametes. In mammals, primary sex determination is commenced by the presence or absence of the Y chromosome, which controls the fate of the gonadal primordium. The somatic precursor of gonads, the genital ridge is formed at the mid-gestation stage and gives rise to one of two organs, a testis or an ovary. The fate of the genital ridge, which is governed by the differentiation of somatic cells into Sertoli cells in the testes or granulosa cells in the ovaries, further determines the sex of an individual and their germ cells. Mutation studies in human patients with disorders of sex development and mouse models have revealed factors that are involved in mammalian sex determination. In most of mammals, a single genetic trigger, the Y-linked gene Sry (sex determination region on Y chromosome), regulates testicular differentiation. Despite identification of Sry in 1990, precise mechanisms underlying the sex determination of bipotential genital ridges are still largely unknown. Here, we review the recent progress that has provided new insights into the mechanisms underlying genital ridge formation as well as the regulation of Sry expression and its functions in male sex determination of mice.

Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned). Knowledge about dimensions of sex and gender in trans populations is crucial to development of inclusive policy, practice, and research, but limited data have been available, particularly from probability samples. The Trans PULSE community-based research project surveyed trans Ontarians (n=433) in 2009-2010 using respondent-driven sampling. Frequencies were weighted by recruitment probability to produce estimates for the networked Ontario trans population. An estimated 30% of trans Ontarians were living their day-to-day lives in their birth gender, and 23% were living in their felt gender with no medical intervention. In all, 42% were using hormones, while 15% of male-to-female spectrum persons had undergone vaginoplasty and 0.4% of female-to-male spectrum persons had had phalloplasty. Of those living in their felt gender, 59% had begun to do so within the past four years. A minority of trans Ontarians reported a linear transition from one sex to another, yet such a trajectory is often assumed to be the norm. Accounting for this observed diversity, we recommend policy and practice changes to increase social inclusion and service access for trans persons, regardless of transition status.

Prevalence of genitalia malformation in Iranian children: findings of a nationwide screening survey at school entry

Background:

Ambiguous genitalia is a hereditary disorder that usually requires early attention and detection. The discovery of ambiguous genitalia in a neonate is situation that could be difficult to manage, not only because of complications such as salt-losing, but also due to the importance of sex determination before psychological gender could be established. Awareness of the prevalence of ambiguous genitalia can affect the attitude and consideration of physicians and related medical personnel about disease in different communities. So in this study, the prevalence of ambiguous genitalia and undescended testes (UDT) in Iran was reported.

Materials and Methods:

This national study was conducted in 2009-2010 as part of the routine screening examinations at school entry in Iran. The physical examinations were performed for students at entry to three school levels by physicians and medical personnel. Execution and conduction of this program was the duty of the University of Medical Sciences in each province.

Results:

On average, the prevalence of ambiguous genitalia was 0.04% at national level (0.03%, 0.05%, and 0.03% at 6, 12, and 15 year olds, respectively). The prevalence of ambiguous genitalia was not significantly different according to age group and living area. The average of UDT) prevalence in the whole country was 0.13%. The prevalence of UDT was higher at elementary school level than in the other two levels.

Conclusion:

Although the prevalence of genitalia abnormalities was not high in the school students in Iran, given the importance of the issue and in order to find the ambiguous genitalia or UDT, medical examinations and parental notification should be taken seriously at an earlier age.

Sexual life and sexual wellness in individuals with complete androgen insensitivity syndrome (CAIS) and Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS)

INTRODUCTION

Sexual wellness depends on a person's physical and psychological constitution. Complete Androgen Insensitivity Syndrome (CAIS) and Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) can compromise sexual well-being.

AIMS

To compare sexual well-being in CAIS and MRKHS using multiple measures: To assess sexual problems and perceived distress. To gain insight into participants' feelings of inadequacy in social and sexual situations, level of self-esteem and depression. To determine how these psychological factors relate to sexual (dys)function. To uncover what participants see as the source of their sexual problems.

METHODS

Data were collected using a paper-and-pencil questionnaire. Eleven individuals with CAIS and 49 with MRKHS with/without neovagina treatment were included. Rates of sexual dysfunctions, overall sexual function, feelings of inadequacy in social and sexual situations, self-esteem and depression scores were calculated. Categorizations were used to identify critical cases. Correlations between psychological variables and sexual function were computed. Sexually active subjects were compared with sexually not active participants. A qualitative content analysis was carried out to explore causes of sexual problems.

MAIN OUTCOME MEASURES

An extended list of sexual problems based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, by the American Psychiatric Association and related distress. Female Sexual Function Index (FSFI), German Questionnaire on Feelings of Inadequacy in Social and Sexual Situations (FUSS social scale, FUSS sexual scale), Rosenberg Self-Esteem Scale (RSE), Brief Symptom Inventory (BSI) subscale depression. Open question on alleged causes of sexual problems.

RESULTS

The results point to a far-reaching lack of sexual confidence and sexual satisfaction in CAIS. In MRKHS apprehension in sexual situations is a source of distress, but sexual problems seem to be more focused on issues of vaginal functioning. MRKHS women report being satisfied with their sex life.

CONCLUSION

Different conditions can affect individuals in diagnosis-specific ways despite some shared clinical features. Professionals should adopt an interdisciplinary approach and provide custom-made care in order to promote sexual well-being in patients.

Evaluation and management of disorders of sex development: multidisciplinary approach to a complex diagnosis

Various disorders of sex development (DSD) result in abnormal development of genitalia, which may be recognized at prenatal ultrasonography, immediately after birth, or later in life. Current methods for diagnosing DSD include a thorough physical examination, laboratory tests to determine hormone levels and identify chromosomal abnormalities, and radiologic imaging of the genitourinary tract and adjacent organs. Because of the complex nature of DSD, the participation of a multidisciplinary team is required to address the patient's medical needs as well as any psychosocial issues that the patient or the family may encounter after the diagnosis. The first step in the management of DSD is sex assignment, which is based on factors such as the genotype; the presence, location, and appearance of reproductive organs; the potential for fertility; and the cultural background and beliefs of the patient's family. The primary goal of sex assignment is to achieve the greatest possible consistency between the patient's assigned sex and his or her gender identity. Once the sex is assigned, the next step in management might be surgery, hormone therapy, or no intervention at all. Patients with ovotesticular DSD and gonadal dysgenesis may require a gonadectomy, followed by reconstructive surgery. Some patients may need hormone replacement therapy during puberty. An understanding of the immediacy of families' need for sex assignment and clinicians' need for reliable diagnostic imaging results will help radiologists participate effectively in the prenatal and postnatal assessment of patients with DSD.

Gadd45g is essential for primary sex determination, male fertility and testis development

In humans and most mammals, differentiation of the embryonic gonad into ovaries or testes is controlled by the Y-linked gene SRY. Here we show a role for the Gadd45g protein in this primary sex differentiation. We characterized mice deficient in Gadd45a, Gadd45b and Gadd45g, as well as double-knockout mice for Gadd45ab, Gadd45ag and Gadd45bg, and found a specific role for Gadd45g in male fertility and testis development. Gadd45g-deficient XY mice on a mixed 129/C57BL/6 background showed varying degrees of disorders of sexual development (DSD), ranging from male infertility to an intersex phenotype or complete gonadal dysgenesis (CGD). On a pure C57BL/6 (B6) background, all Gadd45g(-/-) XY mice were born as completely sex-reversed XY-females, whereas lack of Gadd45a and/or Gadd45b did not affect primary sex determination or testis development. Gadd45g expression was similar in female and male embryonic gonads, and peaked around the time of sex differentiation at 11.5 days post-coitum (dpc). The molecular cause of the sex reversal was the failure of Gadd45g(-/-) XY gonads to achieve the SRY expression threshold necessary for testes differentiation, resulting in ovary and Müllerian duct development. These results identify Gadd45g as a candidate gene for male infertility and 46,XY sex reversal in humans.

Policing the boundaries of sex: a critical examination of gender verification and the Caster Semenya controversy

On August 19, 2009, Caster Semenya, South African track star, won a gold medal in the women's 800-meter event. According to media reports, on the same day, the International Association of Athletics Federations (IAAF) ordered Semenya to undergo gender verification testing. This article critically assesses the main concepts and claims that undergird international sport organizations' policies regarding "gender verification" or "sex testing." We examine the ways in which these policies operate through several highly contested assumptions, including that (a) sex exists as a binary; (b) sport is a level playing field for competitors; and (c) some intersex athletes have an unfair advantage over women who are not intersex and, as such, they should be banned from competition to ensure that sport is a level playing field. To conclude, we make three recommendations that are consistent with the attainment of sex and gender justice in sport, which include acknowledging that myriad physical advantages are accepted in sport, recognizing that sport as a level playing field is a myth, and eliminating sex testing in sport.

Genetic-gonadal-genitals sex (3G-sex) and the misconception of brain and gender, or, why 3G-males and 3G-females have intersex brain and intersex gender

The categorization of individuals as "male" or "female" is based on chromosome complement and gonadal and genital phenotype. This combined genetic-gonadal-genitals sex, here referred to as 3G-sex, is internally consistent in ~99% of humans (i.e., one has either the "female" form at all levels, or the "male" form at all levels). About 1% of the human population is identified as "intersex" because of either having an intermediate form at one or more levels, or having the "male" form at some levels and the "female" form at other levels. These two types of "intersex" reflect the facts, respectively, that the different levels of 3G-sex are not completely dimorphic nor perfectly consistent. Using 3G-sex as a model to understand sex differences in other domains (e.g., brain, behavior) leads to the erroneous assumption that sex differences in these other domains are also highly dimorphic and highly consistent. But parallel lines of research have led to the conclusion that sex differences in the brain and in behavior, cognition, personality, and other gender characteristics are for the most part not dimorphic and not internally consistent (i.e., having one brain/gender characteristic with the "male" form is not a reliable predictor for the form of other brain/gender characteristics). Therefore although only ~1% percent of humans are 3G-"intersex", when it comes to brain and gender, we all have an intersex gender (i.e., an array of masculine and feminine traits) and an intersex brain (a mosaic of "male" and "female" brain characteristics).

How do Individuals with Complete Androgen Insensitivity Syndrome, Mayer-Rokitansky-Küster-Hauser Syndrome or Polycystic Ovary Syndrome Experience Contact to Other Affected Persons?

Persons with different sex characteristics may suffer from a feeling of being "different" or "not normal". In this study, persons with one of 3 diagnoses (complete androgen insensitivity syndrome [CAIS]; Mayer-Rokitansky-Küster-Hauser syndrome [MRKHS], polycystic ovary syndrome [PCOS]) were asked whether they had contact to other affected persons and how they assessed this contact. The correlation between contact and psychological distress was evaluated. Material and Methods: Information on contacts to other affected individuals was obtained using a written questionnaire. Psychological distress was measured using the German version of the BSI (Brief Symptom Inventory). Results: Data from 11 individuals with CAIS, 49 women with MRKHS and 55 women with PCOS was analysed. The frequency of contacts to other affected individuals differed between the different diagnostic groups (with the highest frequency reported for the group with CAIS, and the lowest for the group with PCOS). Overall, the majority of individuals considered such contacts beneficial (CAIS 81.8 %; MRKHS 90 %; PCOS 83.3 %). The frequency of contacts and their assessment were not found to be correlated with psychological distress. The three diagnostic groups differed in the proportion of people who indicated a wish for contact with other affected persons. The desire to have contact with other affected persons was most commonly expressed by women with PCOS and high levels of psychological distress (60.9 %). Conclusion: Persons with different sex characteristics can benefit from contact to other affected individuals. Particularly women with PCOS and increased levels of psychological distress may benefit if the issue of support groups is addressed during treatment.

Laparoscopy versus ultrasonography for the evaluation of Mullerian structures in children with complex disorders of sex development

PURPOSE

The diagnosis of children with disorders of sex development (DSD) requires a karyotype, different biochemical and radiological investigations in the context of a multidisciplinary team. The aim of this study was to compare the diagnostic accuracy of laparoscopy (L) versus ultrasonography (US) in the assessment of children with complex DSD.

METHODS

We retrospectively examined the theatre database searching for children with DSD who underwent laparoscopic surgery from 1999 to 2011. The medical and radiological records were reviewed.

RESULTS

Eighteen patients were identified. Age at diagnosis ranged from birth to 14 years (mean 2.5 years). There were seven patients with 46XY dysgenetic testicular DSD (4 mosaic Turner, 3 mixed gonadal dysgenesis), seven patients with 46XY non-dysgenetic testicular DSD (4 persistent Mullerian duct syndrome, 2 complete androgen insensitivity syndrome, one unknown), two patients with ovotesticular DSD, one patient with 46XX DSD (congenital adrenal hyperplasia) and one patient with 46XY DSD complete sex reversal. Fifteen underwent ultrasonography prior to laparoscopy. Both modalities identified Mullerian structures in seven (47 %) patients, in one (7 %) patient US and L confirmed the absence of Mullerian structures, while in six (40 %) patients there was discordance, with US failing to visualize pelvic Mullerian structures. In the last patient with 46XY non-dysgenetic testicular DSD, the rectum was thought to be a dilated uterus on ultrasonography.

CONCLUSIONS

Pelvic ultrasonography failed to identify Mullerian structures in 40 % of patients with complex DSD. On the contrary, laparoscopy allowed excellent visualization of pelvic structures and gonads in children with complex DSD.

"Mixed germ cell testicular tumor" in an adult female

The androgen insensitivity (testicular feminization) syndrome was described by Morris in phenotypic females with 46XY karyotype, presenting with primary amenorrhea, adequate breast development, and absent or scanty pubic or axillary hair. Gonads consist usually of seminiferous tubules without spermatogenesis. These patients have a 5–10% risk of developing germ cell tumors, usually after the complete development of secondary female sexual characteristics. We hereby report a case considered as a female with married life of 15 years, who was operated for severe abdominal pain. Phenotype characters were that of female. Microscopic examination of the tumor from the abdomen revealed germinoma and yolk sac tumor with adjacent seminiferous tubules. Karyotyping showed 46XY. Final diagnosis of malignant mixed germ cell tumor in androgen insensitivity syndrome was made. Surveillance may be the most appropriate option when these conditions are initially diagnosed in adulthood to prevent development of germ cell tumors.

The intersection of neurotoxicology and endocrine disruption

Endocrine disruption, the guiding theme of the 27th International Neurotoxicology Conference, merged into the neurotoxicology agenda largely because hormones help steer the process of brain development. Although the disruption motif first attracted public health attention because of reproductive anomalies in both wildlife and humans, the neurobehavioral implications had been planted decades earlier. They stemmed from the principle that sex differences in behavior are primarily the outcomes of differences in how the brain is sexually differentiated during early development by gonadal hormones (the Organizational Hypothesis). We also now understand that environmental chemicals are capable of altering these underlying events and processes. Among those chemicals, the group labeled as endocrine disrupting chemicals (EDCs) offers the clearest evidence of such selectivity, a consequence of their actions on the endogenous sex steroids, androgens and estrogens. Two EDCs in particular offer useful and intriguing examples. One is phthalate esters. The other is bisphenol A. Both agents are used extensively in plastics manufacture, and are pervasive in the environment. Both are produced in immense quantities. Both are found in almost all humans. Phthalates are considered to function in essence as anti-androgens, while bisphenol A is labeled as an estrogen. Their associations with brain sexual differentiation are reviewed and further questions noted. Both EDCs produce a wider spectrum of health effects, however, than would be extrapolated simply from their properties as anti-androgens and estrogens. Obesity is one example. Further complicating their assessment as health risks are questions about nonmonotonic dose-response functions and about transgenerational effects incurred via epigenetic mechanisms. All these facets of endocrine disruption are pieces of a puzzle that challenge neurotoxicologists for solutions.

Ambiguous genitalia: what prenatal genetic testing is practical?

Concern for ambiguous genitalia or chromosome-phenotype discordance detected in a prenatal setting has increased over the last two decades. Practitioners faced with this prenatal finding have a variety of genetic tests available to them; however, it is unclear to what extent prenatal testing for disorders of sex development (DSD) is useful or practical. We undertook a retrospective review of the medical records of 140 individuals evaluated through the DSD clinic at Seattle Children's Hospital with birthdates from 01/01/1994 through 08/16/2011 to determine the rate of prenatal detection of ambiguous genitalia in individuals with DSD, what prenatal diagnostic workup was undertaken, and the postnatal outcome, including whether a postnatal genetic diagnosis was confirmed. Of all 140 subjects, 34 (24%) were identified prenatally. The most common postnatal diagnoses were penoscrotal hypospadias with transposition of the scrotum with no known genetic cause (24/140; 17%) and 21-hydroxylase deficiency (20/140; 14%). Apart from these, no single diagnosis comprised more than a few cases. Prenatal diagnostic testing varied widely, from no tests to multiple molecular tests with amniotic fluid hormone concentrations. In the absence of other fetal anomalies or growth retardation on ultrasound, prenatal karyotype with fluorescence in situ hybridization for the SRY gene is the most useful test when ambiguous genitalia is suspected. Further prenatal testing for Smith-Lemli-Opitz syndrome in 46,XY individuals and congenital adrenal hyperplasia in 46,XX individuals may be considered. However, targeted molecular testing for rare DSD conditions in the absence of a family history of DSD has a low yield.

Disorders of sex development

The birth of a new baby is one of the most dramatic events in a family, and the first question is usually "is it a boy or a girl?" The newborn infant with ambiguous external genitalia often comes as a surprise for the doctors as well as the parents and is sometimes described as an endocrine emergency situation presenting a problem of sex assignment. The nomenclature such as 'intersex', 'hermaphrodite', and 'pseudohermaphrodite' is out of date as well as confusing, and many urologists are concerned that these confusing terms could be perceived to be pejorative by some affected families. In response to concerns regarding outdated and controversial terms, the Chicago Consensus held in 2005 recommended new terminology based on the umbrella term disorders of sex differentiation (DSDs). The term DSD has a comprehensive definition including any problem noted at birth in which the genitalia are atypical in relation to the chromosomes or gonads. The karyotype is used as a prefix defining the classification of DSD. DSDs are rare and complex. The optimal management of patients with DSD must be individualized and multidisciplinary, considering all aspects, including psychological care and full disclosure of alternatives relating to surgery type and timing. Although further studies are necessary to confirm guidelines and recommendations fitting for the individual patients with DSD, this article is an attempt to provide a balanced perspective for new taxonomy, clinical evaluation, and medical, surgical, and psychological management of DSD.

Male sex determination: insights into molecular mechanisms

Disorders of sex development often arise from anomalies in the molecular or cellular networks that guide the differentiation of the embryonic gonad into either a testis or an ovary, two functionally distinct organs. The activation of the Y-linked gene Sry (sex-determining region Y) and its downstream target Sox9 (Sry box-containing gene 9) triggers testis differentiation by stimulating the differentiation of Sertoli cells, which then direct testis morphogenesis. Once engaged, a genetic pathway promotes the testis development while actively suppressing genes involved in ovarian development. This review focuses on the events of testis determination and the struggle to maintain male fate in the face of antagonistic pressure from the underlying female programme.

Male or Female? Brains are Intersex

The underlying assumption in popular and scientific publications on sex differences in the brain is that human brains can take one of two forms “male” or “female,” and that the differences between these two forms underlie differences between men and women in personality, cognition, emotion, and behavior. Documented sex differences in brain structure are typically taken to support this dimorphic view of the brain. However, neuroanatomical data reveal that sex interacts with other factors in utero and throughout life to determine the structure of the brain, and that because these interactions are complex, the result is a multi-morphic, rather than a dimorphic, brain. More specifically, here I argue that human brains are composed of an ever-changing heterogeneous mosaic of “male” and “female” brain characteristics (rather than being all “male” or all “female”) that cannot be aligned on a continuum between a “male brain” and a “female brain.” I further suggest that sex differences in the direction of change in the brain mosaic following specific environmental events lead to sex differences in neuropsychiatric disorders.

[Medical and legal aspects of treating ambiguous genitalia]

Treatment of ambiguous genitalia has reached high standards. Damage caused by the anomaly can be reduced significantly or eliminated. In a well-defined minority definite early sex assignment is not possible but preliminary, and surgical genital correction therefore is delayed. Poor results and continuous misunderstandings regarding the nature of intersex caused strong opposition from activist groups against all forms of early diagnosis, sex assignment and surgical treatment. Supported by psychologists and the media, jurisdictional actions are underway trying to change the law and prevent parents from allowing treatment of their children. In addition, institution of a moratorium has been requested to stop genital surgery on children and to establish a third sex of hermaphrodites. All this led to irritations and insecurity concerning treatment and legal risk.Analysis of the current medical situation and the laws concerning the subject reveal that there is no alternative to early sex assignment and treatment, with the exemption of a very small, but defined group. At this moment, there is no realistic legal possibility to remove the right from parents to decide for their children, create a new sex and solve problems of intersex patients by pushing them into"hermaphroditism". This would be a decision against their and their parents' will, in a society which is based on male and female gender.

Identification of SOX3 as an XX male sex reversal gene in mice and humans

Sex in mammals is genetically determined and is defined at the cellular level by sex chromosome complement (XY males and XX females). The Y chromosome-linked gene sex-determining region Y (SRY) is believed to be the master initiator of male sex determination in almost all eutherian and metatherian mammals, functioning to upregulate expression of its direct target gene Sry-related HMG box-containing gene 9 (SOX9). Data suggest that SRY evolved from SOX3, although there is no direct functional evidence to support this hypothesis. Indeed, loss-of-function mutations in SOX3 do not affect sex determination in mice or humans. To further investigate Sox3 function in vivo, we generated transgenic mice overexpressing Sox3. Here, we report that in one of these transgenic lines, Sox3 was ectopically expressed in the bipotential gonad and that this led to frequent complete XX male sex reversal. Further analysis indicated that Sox3 induced testis differentiation in this particular line of mice by upregulating expression of Sox9 via a similar mechanism to Sry. Importantly, we also identified genomic rearrangements within the SOX3 regulatory region in three patients with XX male sex reversal. Together, these data suggest that SOX3 and SRY are functionally interchangeable in sex determination and support the notion that SRY evolved from SOX3 via a regulatory mutation that led to its de novo expression in the early gonad.

Why do ‘we’ perform surgery on newborn intersexed children?

Few parents-to-be consider that their child may be born with ambiguous sex. Still, parents of a newborn child with ambiguous sex are expected to make a far-reaching decision for the child: should the child be operated upon so that it has either female or male genitals? The aim of this article is to examine, phenomenologically, why parents decide to have their children undergo genital surgery when it is not necessary for the child’s physiological functions. Drawing on phenomenological work by Maurice Merleau-Ponty, Simone de Beauvoir and Sara Ahmed, we examine parents’ frustration when their child’s sex is ambiguous and their experiences of the practice of medical sex assignment. We also examine parental identity work when the child has been assigned a sex and the interaction between parents and medical professionals when parents make decisions regarding surgery on their child. Furthermore, we provide a critical perspective on the surgical practice.

Management of ambiguous genitalia in Ile Ife, Nigeria: challenges and outcome

BACKGROUND

Ambiguous genitalia are a major cause of parental anxiety and can create social problems if not properly managed. Diagnosis and management can however be challenging. The aim of this study is to highlight some of the challenges in management of ambiguous genitalia in our environment.

PATIENTS AND METHODS

All cases of ambiguous genitalia managed at the Paediatric surgical unit of the Obafemi Awolowo University Teaching hospital, Ile Ife, Nigeria, between January 1993 and October 2007 were analysed for age, sex at presentation, investigation modality, and final sex of rearing and outcome of surgery.

RESULT

Nine patients had surgical reconstruction for ambiguous genitalia during the study period. Their age ranges from 5 weeks to 19 years at presentation. The causes of genital ambiguity in the patients was congenital adrenal hyperplasia (CAH) in 6, true hermaphroditism in 2 and male pseudo-hermaphroditism in 1. Seven patients were reconstructed as females while 2 were raised as males. Change of sex of raring was necessary in 2 patients.

CONCLUSION

The diagnosis and management of ambiguous genitalia is a challenging problem in our environment. Early presentation and treatment is necessary to avoid psychological and social embarrassment.

Perfil clínico de 62 casos de distúrbios da diferenciação sexual

OBJETIVO: Descrever o perfil clínico dos casos de distúrbios da diferenciação sexual em acompanhamento no Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, no Rio de Janeiro, nos últimos cinco anos. MÉTODOS: Revisão dos prontuários dos pacientes, com o diagnóstico de genitália ambígua em acompanhamento nos últimos cinco anos, segundo os critérios clínicos descritos por Danish, em 1982. O registro mais antigo foi feito em 1981 e o mais recente de junho de 2006. RESULTADOS: Foram encontrados 62 casos de genitália ambígua: 26 com registro do sexo feminino e 36 com registro do sexo masculino. O diagnóstico mais freqüente foi o de hiperplasia congênita de supra-renal (33,9%), seguido de quadros sindrômicos (14,5%) e disgenesias gonadais (9,7%). A média de idade ao diagnóstico foi de 7,2 anos (de zero a 42 anos). CONCLUSÕES: A ambigüidade genital não é uma doença específica, mas um conjunto de alterações que direcionam o clínico a buscar diagnósticos específicos. A freqüência dessa afecção depende dos critérios diagnósticos utilizados. A adoção de critérios amplos aumenta a chance de detecção precoce do quadro bem como de cuidado adequado a crianças com distúrbios da diferenciação sexual.

Health care issues among lesbian, gay, bisexual, transgender and intersex (LGBTI) populations in the United States: Introduction

This supplemental issue of the Journal of Homosexuality presents research that explores a variety of health care issues encountered by lesbian, gay, bisexual, transgender and intersex (LGBTI) population groups in the United States over the 10-year period from 1993 to 2002. Topics include access to health care, utilization of care, training of medical and mental health providers, and the appropriate preparation of clinical offices and waiting areas. Authors used a variety of community-based public health research methods, including participant and provider surveys and retrospective chart reviews of patients, to develop this body of research, providing a recent-historical perspective on the complex health care and health-related needs of sexual and gender minorities. Particularly for transgender and intersex populations, the state of research describing their health care needs is in its infancy, and much remains to be done to design effective medical and mental health programs and interventions.

ORIGINAL RESEARCH–INTERSEX AND GENDER IDENTITY DISORDERS: Male Gender Identity in an XX Individual with Congenital Adrenal Hyperplasia

INTRODUCTION

In spite of significant changes in the management policies of intersexuality, clinical evidence show that not all pubertal or adult individuals live according to the assigned sex during infancy.

AIM

The purpose of this study was to analyze the clinical management of an individual diagnosed as a female pseudohermaphrodite with congenital adrenal hyperplasia (CAH) simple virilizing form four decades ago but who currently lives as a monogamous heterosexual male.

METHODS

We studied the clinical files spanning from 1965 to 1991 of an intersex individual. In addition, we conducted a magnetic resonance imaging (MRI) study of the abdominoplevic cavity and a series of interviews using the oral history method.

MAIN OUTCOME MEASURES

Our analysis is based on the clinical evidence that led to the CAH diagnosis in the 1960s in light of recent clinical testing to confirm such diagnosis.

RESULTS

Analysis of reported values for 17-ketosteroids, 17-hydroxycorticosteroids, from 24-hour urine samples during an 8-year period showed poor adrenal suppression in spite of adherence to treatment. A recent MRI study confirmed the presence of hyperplastic adrenal glands as well as the presence of a prepubertal uterus. Semistructured interviews with the individual confirmed a life history consistent with a male gender identity.

CONCLUSIONS

Although the American Academy of Pediatrics recommends that XX intersex individuals with CAH should be assigned to the female sex, this practice harms some individuals as they may self-identify as males. In the absence of comorbid psychiatric factors, the discrepancy between infant sex assignment and gender identity later in life underlines the need for a reexamination of current standards of care for individuals diagnosed with CAH.

Intersex mental health and social support options in pediatric endocrinology training programs

The birth of a child with an intersex condition is often an emotionally stressful event for parents. Preparation and ongoing support systems could be beneficial to both parents and children and would alleviate some of the shame and isolation associated with intersex conditions. To assess the extent to which psychological support is available, a short e-mail survey on this topic was sent to the directors of 50 pediatric endocrinology fellowship training programs (PEFTPs), who are most likely to evaluate and treat intersex children and their parents. Of the 29 PEFTPs that responded, 69% offer psychological support and 58% have a mental health specialist on staff. However, only 19% of patients or families receive emotional support during diagnosis and only 15% receive support after diagnosis. We found two barriers that prevent patients and families from receiving psychological help from their intersex care team. First, there is a lack of training for mental health professionals regarding the needs of intersex patients and families. Second, some families refuse help even though it is offered. This study reveals that further research is needed to overcome these two barriers regarding mental health treatment of intersex patients and families.

A Gender Assessment Team: experience with 250 patients over a period of 25 years

PURPOSE

To describe a Gender Assessment Team that has provided a multidisciplinary approach to the diagnosis, medical and surgical treatment, genetic counseling, and psychosocial support of patients with ambiguous genitalia, intersex disorders, and other genital anomalies, collectively termed disorders of sex development; and to determine the major diagnostic categories and approach.

METHODS

A retrospective review of 250 patients evaluated by the Team at Children's Hospital and Regional Medical Center in Seattle, WA, from January 1981 through December 2005. The Team included the following specialties: medical genetics, cytogenetics, gynecology, pediatric urology, endocrinology, and psychiatry.

RESULTS

Of the subjects, 177 were infants, 46 were children or adolescents, and 27 had a multisystem genetic condition. The most common diagnoses were congenital adrenal hyperplasia (14%), androgen insensitivity syndrome (10%), mixed gonadal dysgenesis (8%), clitoral/labial anomalies (7%), hypogonadotropic hypogonadism (6%), and 46,XY small-for-gestational-age males with hypospadias (6%).

CONCLUSION

The six most common diagnoses comprised 50% of the cohort. The expertise of a multidisciplinary team allowed for integrated care for patients with disorders of sex development and identification of novel conditions. Geneticists play an important role in a team approach through knowledge of genetic testing options and diagnosis of patients with karyotypic abnormalities and syndromes with genital anomalies.

Sex and the surgeon's knife: the family court's dilemma...informed consent and the specter of iatrogenic harm to children with intersex characteristics

“Sex” is a complex thing. The word conjures up many images according to how it is used. When narrowed to the context of the law, however, a person’s sex can be broken down into three primary categories: biological sex, common law sex, and legal sex.

Biological sex has traditionally been determined according to the presence or absence of genitals and gonads (phenotype), and the configuration of the sex chromosomes (karyotype).

Epidemiology and initial management of ambiguous genitalia at birth in Germany

BACKGROUND

In this epidemiological study, we sought to capture the incidence of ambiguous genitalia in neonates and to describe initial management strategies.

METHODS

We used the registry for rare diseases in pediatrics in Germany to ascertain cases and asked reporting institutions for information on phenotype, laboratory tests, imaging results, diagnosis, initial management and sex assignment.

RESULTS

We identified 80 cases within a 2-year study period and calculated an incidence of 2 per 10,000 births with ambiguous genitalia per year in Germany. Prevalence was higher in infants from non-German family background. In more than 50% of all infants a definite diagnosis was lacking even at the age of 6 months. In those cases where the etiology was confirmed, the most common diagnosis was congenital adrenal hyperplasia, followed by androgen insensitivity syndrome and mixed gonadal dysgenesis. Associated malformations were very common, affecting 37.5% of all infants. Sex assignment was female in 46,XY infants with predominately female phenotype and all 46,XX infants. Early surgery was performed in many cases irrespective whether a definite diagnosis had been established or not. Integrated psychosocial care was the exception rather than the rule.

CONCLUSIONS

Classification and management of ambiguous genitalia at birth remain a challenge for all professionals involved. National and international registries may help to provide a better understanding of the incidence and clinical course of such disorders.

Potential determinant factors of sexual identity in ambiguous genitalia

This is a review of literature scanning the potential factors which may affect Sexual Identity (S.I.) and Gender Identity (G.I.) in patients with ambiguous genitalia. Definitions of these concepts are outlined. Genetic, gonadal, hormonal, social and cultural pressures are reviewed as well as lessons to learn from clinical experiences and outcomes. Current criteriae used to assign gender in a child with ambiguous genitalia are discussed including medical and surgical criteriae as well as cultural disruptors. At the dawn of the third millennium, it is remarkable how little we know about the establishment of our individual and social identities.