301
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Griffiths DA. Shifting syndromes: Sex chromosome variations and intersex classifications. SOCIAL STUDIES OF SCIENCE 2018; 48:125-148. [PMID: 29424285 PMCID: PMC5808814 DOI: 10.1177/0306312718757081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The 2006 'Consensus statement on management of intersex disorders' recommended moving to a new classification of intersex variations, framed in terms of 'disorders of sex development' or DSD. Part of the rationale for this change was to move away from associations with gender, and to increase clarity by grounding the classification system in genetics. While the medical community has largely accepted the move, some individuals from intersex activist communities have condemned it. In addition, people both inside and outside the medical community have disagreed about what should be covered by the classification system, in particular whether sex chromosome variations and the related diagnoses of Turner and Klinefelter's syndromes should be included. This article explores initial descriptions of Turner and Klinefelter's syndromes and their subsequent inclusion in intersex classifications, which were increasingly grounded in scientific understandings of sex chromosomes that emerged in the 1950s. The article questions the current drive to stabilize and 'sort out' intersex classifications through a grounding in genetics. Alternative social and historical definitions of intersex - such as those proposed by the intersex activists - have the potential to do more justice to the lived experience of those affected by such classifications and their consequences.
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302
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Barseghyan H, Symon A, Zadikyan M, Almalvez M, Segura EE, Eskin A, Bramble MS, Arboleda VA, Baxter R, Nelson SF, Délot EC, Harley V, Vilain E. Identification of novel candidate genes for 46,XY disorders of sex development (DSD) using a C57BL/6J-Y POS mouse model. Biol Sex Differ 2018; 9:8. [PMID: 29378665 PMCID: PMC5789682 DOI: 10.1186/s13293-018-0167-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 01/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) have an estimated frequency of 0.5% of live births encompassing a variety of urogenital anomalies ranging from mild hypospadias to a discrepancy between sex chromosomes and external genitalia. In order to identify the underlying genetic etiology, we had performed exome sequencing in a subset of DSD cases with 46,XY karyotype and were able to identify the causative genetic variant in 35% of cases. While the genetic etiology was not ascertained in more than half of the cases, a large number of variants of unknown clinical significance (VUS) were identified in those exomes. METHODS To investigate the relevance of these VUS in regards to the patient's phenotype, we utilized a mouse model in which the presence of a Y chromosome from the poschiavinus strain (Y POS ) on a C57BL/6J (B6) background results in XY undervirilization and sex reversal, a phenotype characteristic to a large subset of human 46,XY DSD cases. We assessed gene expression differences between B6-Y B6 and undervirilized B6-Y POS gonads at E11.5 and identified 515 differentially expressed genes (308 underexpressed and 207 overexpressed in B6-Y POS males). RESULTS We identified 15 novel candidate genes potentially involved in 46,XY DSD pathogenesis by filtering the list of human VUS-carrying genes provided by exome sequencing with the list of differentially expressed genes from B6-Y POS mouse model. Additionally, we identified that 7 of the 15 candidate genes were significantly underexpressed in the XY gonads of mice with suppressed Sox9 expression in Sertoli cells suggesting that some of the candidate genes may be downstream of a well-known sex determining gene, Sox9. CONCLUSION The use of a DSD-specific animal model improves variant interpretation by correlating human sequence variants with transcriptome variation.
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Affiliation(s)
- Hayk Barseghyan
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Aleisha Symon
- Department of Brain and Gender, Hudson Institute of Medical Research, Clayton, VIC 3168 Australia
| | - Mariam Zadikyan
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Miguel Almalvez
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Eva E. Segura
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Ascia Eskin
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Matthew S. Bramble
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Valerie A. Arboleda
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Ruth Baxter
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Stanley F. Nelson
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Vincent Harley
- Department of Brain and Gender, Hudson Institute of Medical Research, Clayton, VIC 3168 Australia
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
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303
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Guaragna-Filho G, Calixto AR, De Paula GB, De Oliveira LC, Morcillo AM, De Mello MP, Maciel-Guerra AT, Guerra-Junior G. Comparison between two inhibin B ELISA assays in 46,XY testicular disorders of sex development (DSD) with normal testosterone secretion. J Pediatr Endocrinol Metab 2018; 31:191-194. [PMID: 29306929 DOI: 10.1515/jpem-2017-0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/01/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Inhibin B is a hormone produced by the Sertoli cells that can provide important information for the investigation of disorders of sex development (DSD) with 46,XY karyotype. The aim of this study is to compare two enzyme-linked immunosorbent assay (ELISA) assays for dosage of serum inhibin B in patients with 46,XY DSD with normal testosterone secretion. METHODS Twenty-nine patients with 46,XY DSD and normal testosterone secretion (partial androgen insensitivity syndrome [PAIS] [n=8]; 5α-reductase deficiency [n=7] and idiopathic 46,XY DSD [n=14]) were included. Molecular analysis of the AR and SRD5A2 genes were performed in all patients and the NR5A1 gene analysis in the idiopathic group. Measurements of inhibin B were performed by two second-generation ELISA assays (Beckman-Coulter and AnshLabs). Assays were compared using the interclass correlation coefficient (ICC) and the Bland-Altman method. RESULTS ICC was 0.915 [95% confidence interval (CI): 0.828-0.959], however, a discrepancy was observed between trials, which is more evident among higher values when analyzed by the Bland-Altman method. CONCLUSIONS It is recommended to perform the inhibin B measurement always using the same ELISA kit when several evaluations are required for a specific patient.
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Affiliation(s)
- Guilherme Guaragna-Filho
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), School of Medicine, State University of Campinas (UNICAMP),R. Tessalia Vieira de Camargo, 126, Campinas, São Paulo 13083-887, Brazil
| | - Antônio Ramos Calixto
- Laboratory of Investigation in Metabolism and Diabetes (LIMED), UNICAMP, Campinas, São Paulo, Brazil
| | - Georgette Beatriz De Paula
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), School of Medicine, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | | | | | | | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), School of Medicine, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), School of Medicine, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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304
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Rowlands S, Amy JJ. Preserving the reproductive potential of transgender and intersex people. EUR J CONTRACEP REPR 2018; 23:58-63. [DOI: 10.1080/13625187.2017.1422240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sam Rowlands
- Centre of Postgraduate Medical Research & Education, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
| | - Jean-Jacques Amy
- Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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305
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Ediati A, Verrips GHW, Juniarto AZ, Faradz SMH, Drop SLS, Dessens AB. Quality of Life in Late-Treated Patients With Disorders of Sex Development: Insights for Patient-Centered Care. Front Pediatr 2018; 6:434. [PMID: 30805316 PMCID: PMC6371023 DOI: 10.3389/fped.2018.00434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/28/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Patients with a disorder of sex development (DSD) are born with atypical genitals or may develop atypical genitals and atypical body appearance, if left untreated. Health related quality of life (HRQoL) was assessed in Indonesian patients to whom diagnostic procedures and medical intervention had been delayed. Method: Comparison of 118 patients born with DSD, aged 6-41 years (60 children, 24 adolescents, and 34 adults) and 118 healthy control subjects matched for gender, age, and residential setting. HRQoL was measured using a translation of the TACQOL/TAAQOL. Results: According to parental and children's report, children with DSD reported more problems in social functioning and had less positive moods. Girls, in particular, reported problems in cognitive functioning. Adult patients reported more depressive moods, especially women, who reported more anger. No differences were found between in the adolescent groups. Conclusion: The data suggest that Indonesian children with DSD experienced more problems in social contact than non-affected Indonesian children, whereas Indonesian adults with DSD suffered from negative emotions more often than non-affected Indonesians. These findings on HRQoL are in line with findings on emotional functioning.
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Affiliation(s)
- Annastasia Ediati
- Faculty of Psychology, Diponegoro University, Semarang, Indonesia.,Faculty of Medicine, Center for Biomedical Research, Diponegoro University, Semarang, Indonesia
| | - Gijsbert H W Verrips
- Healthy Living, Child Health, Netherlands Organisation for Applied Scientific Research TNO, Leiden, Netherlands
| | - Achmad Zulfa Juniarto
- Faculty of Medicine, Center for Biomedical Research, Diponegoro University, Semarang, Indonesia.,Dr. Kariadi Hospital, Semarang, Indonesia
| | - Sultana M H Faradz
- Faculty of Medicine, Center for Biomedical Research, Diponegoro University, Semarang, Indonesia.,Dr. Kariadi Hospital, Semarang, Indonesia
| | - Stenvert L S Drop
- Department of Pediatrics, Erasmus Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Arianne B Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, Netherlands
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306
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Konrade I, Zavorikina J, Fridvalde A, Rots D, Kalere I, Strumfa I, Dambrova M, Gailite L. Novel Variant of the Androgen Receptor Gene in a Patient With Complete Androgen Insensitivity Syndrome and Polyorchidism. Front Endocrinol (Lausanne) 2018; 9:795. [PMID: 30705665 PMCID: PMC6345100 DOI: 10.3389/fendo.2018.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: Complete androgen insensitivity (CAIS) in 65-95% cases is caused by pathogenic allelic variants (mutations) in the gene encoding androgen receptor (AR gene) and is characterized by female phenotype development with a male karyotype (46, XY). Patients are usually diagnosed during puberty and undergo gonadectomy due to increased testicular germ cell tumor risk. Only a few outcomes have been reported in older individuals with postponed gonadectomy. Case presentation: A 48-year-old CAIS patient presented with polyorchidism (four testes) without gonadal malignancies. Genetic testing identified a novel allelic variant in the AR gene [c.2141T>G (p.Phe805Cys)] causing the clinical symptoms. Conclusion: We have described a unique patient with CAIS and polyorchidism without malignancies in her late 40's bearing a novel likely pathogenic variant in the AR gene.
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Affiliation(s)
- Ilze Konrade
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
- Department of Endocrinology, Riga East University Hospital, Riga, Latvia
| | - Julija Zavorikina
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
| | - Aija Fridvalde
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
| | - Dmitrijs Rots
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, Riga, Latvia
| | - Ieva Kalere
- Department of Pharmacy, Riga Stradins University, Riga, Latvia
| | - Ilze Strumfa
- Department of Pathology, Riga Stradins University, Riga, Latvia
| | - Maija Dambrova
- Department of Human Physiology and Biochemistry, Riga Stradins University, Riga, Latvia
| | - Linda Gailite
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, Riga, Latvia
- *Correspondence: Linda Gailite
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307
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Sharkey CM, Bakula DM, Wolfe-Christensen C, Austin P, Baskin L, Bernabé KJ, Chan YM, Cheng EY, Delozier AM, Diamond DA, Ellens RE, Fried A, Galan D, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Nokoff NJ, Scott Reyes KJ, Palmer B, Poppas DP, Paradis A, Tishelman A, Yerkes EB, Chaney JM, Wisniewski AB, Mullins LL. Parent-Rated Severity of Illness and Anxiety among Caregivers of Children Born with a Disorder of Sex Development Including Ambiguous Genitalia. Horm Res Paediatr 2018; 90:308-313. [PMID: 30566934 PMCID: PMC6421083 DOI: 10.1159/000495422] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/14/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Parents of children born with disorders of sex development (DSD) often experience anxiety, but risk factors, including parental perception of the severity of their child's DSD, have not been examined. We hypothesized that severity of illness (SOI) ratings would relate to parental anxiety, and would be higher for parents of children with a potentially life-threatening DSD (e.g., 21-hydroxylase deficiency). METHODS Eighty-nine parents (Mage = 33.0, 56.2% mothers) of 51 children (Mage in months = 8.7) with a DSD including ambiguous genitalia were recruited from 12 specialized DSD clinics. Parents completed questionnaires prior to genitoplasty, 6 months post-genitoplasty, and 12 months post-genitoplasty (if completed). Data were analyzed with linear mixed modeling. RESULTS Parental anxiety decreased over time, χ2(1) = 10.14, p < 0.01. A positive relationship between SOI and anxiety was found, with SOI being a strong predictor of anxiety (b = 0.53, p < 0.01; χ2[1] = 5.33, p < 0.05). An SOI by time interaction indicated SOI had an increasing effect on anxiety over time, b = 0.06, p < 0.05; χ2(1) = 6.30, p < 0.05. There was no diagnosis by SOI interaction. CONCLUSION Parental anxiety decreased over time, but those with higher SOI ratings reported greater initial anxiety followed by slower resolution over time. Underlying etiology of DSD had no effect on the relationship between SOI and anxiety.
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Affiliation(s)
| | | | | | | | - Laurence Baskin
- University of California San Francisco Medical Center, San Francisco, CA
| | - Kerlly J. Bernabé
- Komansky Children’s Hospital, New York Presbyterian Weill Cornell Medicine, New York, NY
| | | | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | | | | | | | - Denise Galan
- Komansky Children’s Hospital, New York Presbyterian Weill Cornell Medicine, New York, NY
| | | | - Thomas Kolon
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | - Theresa Meyer
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | | | | | - Dix P. Poppas
- Komansky Children’s Hospital, New York Presbyterian Weill Cornell Medicine, New York, NY
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308
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The Sexual Differentiation of the Human Brain: Role of Sex Hormones Versus Sex Chromosomes. Curr Top Behav Neurosci 2018; 43:45-67. [PMID: 30599078 DOI: 10.1007/7854_2018_70] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Men and women differ, not only in their anatomy but also in their behavior. Research using animal models has convincingly shown that sex differences in the brain and behavior are induced by sex hormones during a specific, hormone-sensitive period during early development. Thus, male-typical psychosexual characteristics seem to develop under the influence of testosterone, mostly acting during early development. By contrast, female-typical psychosexual characteristics may actually be organized under the influence of estradiol during a specific prepubertal period. The sexual differentiation of the human brain also seems to proceed predominantly under the influence of sex hormones. Recent studies using magnetic resonance imaging have shown that several sexually differentiated aspects of brain structure and function are female-typical in women with complete androgen insensitivity syndrome (CAIS), who have a 46 XY karyotype but a female phenotype due to complete androgen resistance, suggesting that these sex differences most likely reflect androgen action, although feminizing effects of estrogens or female-typical socialization cannot be ruled out. By contrast, some male-typical neural characteristics were also observed in women with CAIS suggesting direct effects of sex chromosome genes in the sexual differentiation of the human brain. In conclusion, the sexual differentiation of the human brain is most likely a multifactorial process including both sex hormone and sex chromosome effects, acting in parallel or in combination.
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309
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Nahata L. The Gender Reveal: Implications of a Cultural Tradition for Pediatric Health. Pediatrics 2017; 140:peds.2017-1834. [PMID: 29175971 DOI: 10.1542/peds.2017-1834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Leena Nahata
- Division of Endocrinology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio and Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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310
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Johnson EK, Rosoklija I, Finlayson C, Chen D, Yerkes EB, Madonna MB, Holl JL, Baratz AB, Davis G, Cheng EY. Attitudes towards "disorders of sex development" nomenclature among affected individuals. J Pediatr Urol 2017; 13:608.e1-608.e8. [PMID: 28545802 DOI: 10.1016/j.jpurol.2017.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Although now commonly used in medicine, the updated "disorders of sex development" (DSD) nomenclature formally introduced in 2006 has never been universally accepted by members of the affected community, particularly advocacy groups. Use of this nomenclature by medical professionals may unintentionally negatively affect access to healthcare and research for individuals with DSD conditions. OBJECTIVE Among individuals affected by various DSD diagnoses, this study sought to (1) evaluate attitudes towards potentially controversial DSD terminology, (2) determine potential impact of terminology on how affected individuals access healthcare, and (3) explore alternate terms. STUDY DESIGN A web-based survey was developed in collaboration with the AIS-DSDSG (Androgen Insensitivity Syndrome-DSD Support Group) leadership. AIS-DSDSG members (caregivers and affected individuals) were surveyed about attitudes towards DSD, potential impact on healthcare utilization, and alternate terms. A qualitative analysis of reasons for using/avoiding specific terms was performed. RESULTS Surveys were completed by 202 out of 580 (35%) AIS-DSDSG members (61% affected, 39% caregivers; 16% non-gender binary; age range of affected individuals 0-86 years). Only 24% use disorder of sex development to describe themselves/their child. A majority (69%) had a negative emotional experience because of clinical use of nomenclature; 81% changed their care because of it. Preferred and non-preferred terms for clinical care and research are illustrated in the figure. Preferred diagnostic terms were intersex, variation in sex development, and difference of sex development (55%, 52%, and 50% liked/strongly liked, respectively). Disorder of sex development was not preferred (17% liked/strongly liked). About one-third reported that they would not attend a clinic named the Disorder of Sex Development Clinic. Overall, 81% provided qualitative comments; flexible terminology use was a key theme. DISCUSSION These study findings are consistent with previous studies that demonstrated negative perceptions of DSD nomenclature. This study adds to previous findings by surveying a large group of affected individuals with a range of diagnoses, and by exploring emotional impact and healthcare utilization. Several possible alternative terms were also defined. The study was limited by inclusion of only members of AIS-DSDSG, a convenience sample where complete AIS is over-represented, and whose views may not represent the opinion of all individuals with DSD conditions. CONCLUSIONS A group of affected individuals and parents have negative views about the DSD terminology commonly used by medical professionals. Use of certain terms may affect the choice of healthcare provider/institution. Evaluation of DSD terminology in other affected individuals, and re-evaluation of current nomenclature, in collaboration with advocates, is needed.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Courtney Finlayson
- Division Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Arlene B Baratz
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, University of Nevada, Las Vegas, NV, USA; Department of Radiology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Georgiann Davis
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, University of Nevada, Las Vegas, NV, USA; Department of Sociology, University of Nevada, Las Vegas, NV, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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311
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Fabbri-Scallet H, de Mello MP, Guerra-Júnior G, Maciel-Guerra AT, de Andrade JGR, de Queiroz CMC, Monlleó IL, Struve D, Hiort O, Werner R. Functional characterization of five NR5A1
gene mutations found in patients with 46,XY disorders of sex development. Hum Mutat 2017; 39:114-123. [DOI: 10.1002/humu.23353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/18/2017] [Accepted: 10/09/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Helena Fabbri-Scallet
- Center for Molecular Biology and Genetic Engineering - CBMEG; State University of Campinas; São Paulo Brazil
| | - Maricilda Palandi de Mello
- Center for Molecular Biology and Genetic Engineering - CBMEG; State University of Campinas; São Paulo Brazil
| | - Gil Guerra-Júnior
- Department of Pediatrics; Faculty of Medical Sciences; State University of Campinas; São Paulo Brazil
- Interdisciplinary Group for the Study of Sex Determination and Differentiation - GIEDDS; State University of Campinas; São Paulo Brazil
| | - Andréa Trevas Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation - GIEDDS; State University of Campinas; São Paulo Brazil
- Department of Medical Genetics; Faculty of Medical Sciences; State University of Campinas; São Paulo Brazil
| | - Juliana Gabriel Ribeiro de Andrade
- Interdisciplinary Group for the Study of Sex Determination and Differentiation - GIEDDS; State University of Campinas; São Paulo Brazil
- Department of Medical Genetics; Faculty of Medical Sciences; State University of Campinas; São Paulo Brazil
| | | | - Isabella Lopes Monlleó
- Clinical Genetics Service; Faculty of Medicine; Federal University of Alagoas; Maceió Alagoas Brazil
| | - Dagmar Struve
- Department of Paediatric and Adolescent Medicine; Division of Paediatric Endocrinology and Diabetes; Center of Brain; Behavior and Metabolism; University of Luebeck; Luebeck Germany
| | - Olaf Hiort
- Department of Paediatric and Adolescent Medicine; Division of Paediatric Endocrinology and Diabetes; Center of Brain; Behavior and Metabolism; University of Luebeck; Luebeck Germany
| | - Ralf Werner
- Department of Paediatric and Adolescent Medicine; Division of Paediatric Endocrinology and Diabetes; Center of Brain; Behavior and Metabolism; University of Luebeck; Luebeck Germany
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312
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Viau-Colindres J, Axelrad M, Karaviti LP. Bringing Back the Term "Intersex". Pediatrics 2017; 140:peds.2017-0505. [PMID: 29070532 DOI: 10.1542/peds.2017-0505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Marni Axelrad
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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313
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Recommendations for the Establishment of Disorders/Differences of Sex Development Interdisciplinary Care Clinics for Youth. J Pediatr Nurs 2017; 37:79-85. [PMID: 28888337 DOI: 10.1016/j.pedn.2017.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Provide recommendations for the development of an interdisciplinary care (IDC) clinic for the treatment of youth with disorders/differences of sex development (DSD). DSD consist of a group of complex congenital medical disorders in which the development of chromosomal, gonadal, or anatomical sex is atypical. Youth with DSD require care from multiple specialized healthcare disciplines, including several medical specialties, surgery, nursing, and mental health. METHOD Recommendations are based on an interdisciplinary care clinic model that allows for a team of relevant professionals who share knowledge, ideas, and responsibility of care. The framework established in this article is based largely on experiences at an established DSD clinic, as well as observations of multiple clinics across the United States. RESULTS Preliminary outcome data on clinic adherence to treatment protocol under an IDC model are provided. CONCLUSIONS To meet the diverse healthcare needs of youth with DSD, comprehensive care clinics are recommended; however, few such clinics exist in the United States. Establishing new comprehensive DSD clinics can be challenging due to the highly unique treatment of DSD, but the current paper expands the literature available to guide clinic development in the United States.
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314
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Nahata L, Quinn GP. Expanding Parental Permission in Pediatric Treatment: A Hasty Generalization. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:29-30. [PMID: 29111930 DOI: 10.1080/15265161.2017.1378758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Leena Nahata
- a The Research Institute at Nationwide Children's Hospital and The Ohio State University College of Medicine
| | - Gwendolyn P Quinn
- b Moffitt Cancer Center , The University of South Florida, and New York University
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315
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Sudai M. Changing ethical and legal norms in the management of differences of sex development. Lancet Diabetes Endocrinol 2017; 5:764-766. [PMID: 28237790 DOI: 10.1016/s2213-8587(17)30043-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/01/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Maayan Sudai
- Harvard Law School, Harvard University, Cambridge, MA 02138, USA.
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316
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Indyk JA. Disorders/differences of sex development (DSDs) for primary care: the approach to the infant with ambiguous genitalia. Transl Pediatr 2017; 6:323-334. [PMID: 29184813 PMCID: PMC5682373 DOI: 10.21037/tp.2017.10.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The initial management of the neonate with ambiguous genitalia can be a very stressful and anxious time for families, as well as for the general practitioner or neonatologist. A timely approach must be sensitive and attend to the psychosocial needs of the family. In addition, it must also effectively address the diagnostic dilemma that is frequently seen in the care of patients with disorders of sex development (DSDs). One great challenge is assigning a sex of rearing, which must take into account a variety of factors including the clinical, biochemical and radiologic clues as to the etiology of the atypical genitalia (AG). However, other important aspects cannot be overlooked, and these include parental and cultural views, as well as the future outlook in terms of surgery and fertility potential. Achieving optimal outcomes requires open and transparent dialogue with the family and caregivers, and should harness the resources of a multidisciplinary team. The multiple facets of this approach are outlined in this review.
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Affiliation(s)
- Justin A Indyk
- Section of Endocrinology, Nationwide Children's Hospital, the Ohio State University, Columbus, Ohio 43205, USA
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317
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Fernandez N, Moreno O, Rojas A, Céspedes C, Forero C, Mora L, Suarez F, Auli J, Pérez J. Manejo transdisciplinario de pacientes con desórdenes del desarrollo sexual en Colombia. Limitantes para un manejo oportuno e integral. Rev Urol 2017. [DOI: 10.1016/j.uroco.2016.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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318
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Dessens A, Guaragna-Filho G, Kyriakou A, Bryce J, Sanders C, Nordenskjöld A, Rozas M, Iotova V, Ediati A, Juul A, Krawczynski M, Hiort O, Faisal Ahmed S. Understanding the needs of professionals who provide psychosocial care for children and adults with disorders of sex development. BMJ Paediatr Open 2017; 1:e000132. [PMID: 29637150 PMCID: PMC5843008 DOI: 10.1136/bmjpo-2017-000132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Disorders in sex development (DSD) can be treated well medically, but families will encounter many psychosocial challenges. Promoting counselling to facilitate acceptance and coping is important yet equality of access is unknown. This study investigated the modalities of psychosocial care provided in centres of DSD care. METHODS An international survey conducted among 93 providers of psychosocial care, identified through clinical networks, registries and professional forums. RESULTS Forty-six respondents from 22 different countries filled out the survey (49%). Most respondents (78%) were based in hospital-based expert teams. Referrals came from paediatric endocrinologists (76%), gynaecologists (39%) and paediatric urologists (37%). Psychological counselling was most frequently given to parents (74%), followed by children (39%), adolescents (37%) and adults (11%) and was most frequently focused on coping and acceptance of DSD (54%), education (52%), the atypical body (39%) and genital (41%), decisions on genital surgery (33%), complications with sexual intercourse (29%), disclosure (28%) and acceptance of infertility (11%). Respondents most frequently observed DSD related confusion about gender (54%), acceptance of cross gender behaviour (50%), anxiety (43%) and sadness and depression (38%). CONCLUSIONS Most psychosocial care is provided to parents. It is assumed that parental support is important as acceptance is conditional to become affectionate caretakers. Although it may be more difficult for youngsters to communicate about their condition and treatment, providing opportunity to bring up issues that are important for them, is imperative. Clinicians and parents should be aware that parental and patients' interests may not correspond completely. Psychosocial management should also include transition and adult care.
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Affiliation(s)
- Arianne Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus Medical Center Rotterdam - Sophia, Rotterdam, The Netherlands
| | - Guilherme Guaragna-Filho
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Jillian Bryce
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Caroline Sanders
- University of Northern British Columbia, Canada & Adjunct Alder Hey Children Hospital, NHS Trust UK, Prince George, Canada
| | - Agneta Nordenskjöld
- Paediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Marta Rozas
- GrApSIA (Grupo de Apoyo al Síndrome de Insensibilidad a los Andrógenos), Barcelona, Spain
| | - Violeta Iotova
- Department of Paediatrics, Medical University of Varna, Varna, Bulgaria
| | - Annastasia Ediati
- Department of Clinical Psychology, Diponegoro University, Semarang, Indonesia
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maciej Krawczynski
- Department of Medical Genetics, Poznan University of Medical Science, Poznań, Poland
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
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319
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Röhle R, Gehrmann K, Szarras-Czapnik M, Claahsen-van der Grinten H, Pienkowski C, Bouvattier C, Cohen-Kettenis P, Nordenström A, Thyen U, Köhler B. Participation of adults with disorders/differences of sex development (DSD) in the clinical study dsd-LIFE: design, methodology, recruitment, data quality and study population. BMC Endocr Disord 2017; 17:52. [PMID: 28821302 PMCID: PMC5562972 DOI: 10.1186/s12902-017-0198-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND dsd-LIFE is a comprehensive cross-sectional clinical outcome study of individuals with disorders/differences of sex development (DSD). This study focuses on various rare genetic conditions characterized by impaired gonadal or adrenal functionality. METHODS/DESIGN The study aims to assess quality of life (QoL) as a measure of psychosocial adaptation, psychosexual and mental health aspects as major outcomes. Health status and functioning, medical and surgical therapies, participants' views on health care, psychological and social support, sociodemographic factors and their interrelations will be investigated as factors associated with the outcomes. In addition, ethical considerations in the field of DSD are addressed and previous experiences with health care were gathered. One thousand and forty participants with different DSD conditions were recruited by 14 study centres in 6 European countries (France, Germany, the Netherlands, Poland, Sweden and the United Kingdom) from February 2014 until September 2015. The conditions included were: Turner syndrome (n = 301); 45,X0/46,XY conditions (n = 45); Klinefelter syndrome (n = 218); 47,XYY (n = 1); 46,XY gonadal dysgenesis/ovotestes (n = 63); complete androgen insensitivity (CAIS) (n = 71); partial androgen insensitivity (PAIS) (n = 35) and androgen synthesis disorders (n = 20); severe hypospadias (n = 25); other or non-classified 46,XY DSD (n = 8); 46,XX congenital adrenal hyperplasia (CAH) (n = 226); 46,XX gonadal dysgenesis/ovotestis (n = 21); and 46,XX in males (n = 6). For an add-on study, 121 46,XY male-assigned individuals with CAH due to 21-hydroxylase deficiency were recruited. Mean age of participants' was 32.4 (+/- 13.6 years). DISCUSSION Participation was high in conditions not commonly described as DSD, such as Turner and Klinefelter syndromes or CAH. Recruitment of individuals with XY DSD conditions proved to be more difficult. The data collection of PROs resulted in high data quality. Within medical and physical examination data, more missings and/or inaccurate data were found than expected. The European dsd-LIFE study recruited and evaluated the largest cross-sectional sample of individuals with different conditions classified under the term DSD. The data from this large sample will provide a sufficient basis for evidence-based recommendations for improvement of clinical care of individuals affected by a DSD condition. TRIAL REGISTRATION German Clinical Trials Register DRKS00006072 .
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Affiliation(s)
- Robert Röhle
- Koordinierungszentrum Klinische Studien, (KKS), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Gehrmann
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maria Szarras-Czapnik
- Clinic of Endocrinology and Diabetology, Children’s Memorial Health Institute, Warszawa, Poland
| | | | - Catherine Pienkowski
- Unite d’Endocrinologie, Genetique et Gynecologie medicale, Hopital des Enfants, Toulouse, France
| | - Claire Bouvattier
- Endocrinologie pediatrique, Centre de reference des maladies rares du developpement sexuel, Hopital Bicêtre, Universite Paris-Sud, Paris, France
| | - Peggy Cohen-Kettenis
- Medische psychologie en medisch maatschappelijk werk, VU Medisch Centrum, Amsterdam, The Netherlands
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Department of Paediatric Endocrinology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin, Universität zu Lübeck, Lübeck, Germany
| | - Birgit Köhler
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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320
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Raveenthiran V. Neonatal Sex Assignment in Disorders of Sex Development: A Philosophical Introspection. J Neonatal Surg 2017; 6:58. [PMID: 28920018 PMCID: PMC5593477 DOI: 10.21699/jns.v6i3.604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 06/11/2017] [Indexed: 11/11/2022] Open
Abstract
Management of ambiguous genitalia is highly controversial. This condition was known previously as intersex and presently as disorders of sex development (DSD). There is no consensus regarding the choice, timing and method of sex assignment in neonates with DSD. Consensus conferences could not unify the views of various stakeholders and third parties. This article philosophically examines the nature and origin of such controversies. Misconception, bias and conflicting priorities are identified as the three cardinal sources of controversies. Conceptual duality of sexes, confused notion of sex and gender, bias towards penetrative intercourse, conflict between utopian ideals and reality, unwillingness to compromise are identified as perpetuators of controversies. Suggestions are made regarding sex assignment in various types of DSD based on the understanding of published literature and the author's personal experience.
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Affiliation(s)
- V Raveenthiran
- Department of Pediatric Surgery, Sri Ramasamy Memorial (SRM) Medical College SRM University, Chennai, India
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321
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Johnson EK, Rosoklija I, Shurba A, D'Oro A, Gordon EJ, Chen D, Finlayson C, Holl JL. Future fertility for individuals with differences of sex development: Parent attitudes and perspectives about decision-making. J Pediatr Urol 2017; 13:402-413. [PMID: 28713007 DOI: 10.1016/j.jpurol.2017.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/20/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Children, adolescents, and young adults (children/youth) with differences/disorders of sex development (DSD) face challenges related to future fertility; this may be due to variations in gonadal development, and, for some, gonadectomy performed to reduce the risk of malignancy. Childhood may be the only time for preservation of biological fertility potential for children/youth who undergo gonadectomy or have early gonadal failure. Fertility-related decision-making for these patients is particularly complicated, due to the need for parental proxy decision-making, potential discordance between gender identity and gonadal type, and uncertain future assisted reproductive technologies. OBJECTIVE This study aimed to assess: (1) attitudes regarding future fertility, and (2) healthcare needs for fertility-related decision-making among parents of children/youth with DSD. STUDY DESIGN Semi-structured qualitative interviews about future fertility were conducted with parents of children/youth with DSD. Parents who had never discussed fertility with a healthcare provider were excluded. Grounded theory methodology was used to identify emergent themes and patterns. Demographics and clinical characteristics were assessed via survey and medical chart review. RESULTS Nineteen parents were interviewed (participation rate: 60%, 14 mothers/5 fathers, median patient age at diagnosis 6 months (range 0-192), eight DSD diagnoses). The most common emergent themes are summarized in the Summary Table. Most parents identified fertility as a key concern, both at time of diagnosis and throughout development. Parents expressed difficulty with timing of disclosure about potential infertility to their children. Multiple preferences related to medical decision-making about future fertility and fertility preservation were expressed, including: a desire for step-by-step decision-making, and use of medically vetted information and research to guide decisions. DISCUSSION This qualitative study provided new information about the perspectives of parents of children/youth with DSD regarding future fertility. Previous studies have suggested that the possibility of biological parenthood is important to many individuals with DSD. This study provided an in-depth parental perspective. This is important because many decisions that affect future fertility are made in childhood, and require parents to make decisions on behalf of their children. The study sample was limited in its geographic diversity. Strengths of the study included diversity in age of the child/youth, ethnic backgrounds, and the DSD diagnoses that were represented. CONCLUSIONS Future fertility was a concern for many parents of children/youth with DSD. Parents expressed multiple priorities and preferences related to making difficult fertility-related medical decisions for their children. Many of the study findings could be incorporated into future best practices for discussions about fertility with families of children/youth with DSD.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Angela Shurba
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Anthony D'Oro
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elisa J Gordon
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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322
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Özen S, Onay H, Atik T, Solmaz AE, Özkınay F, Gökşen D, Darcan Ş. Rapid Molecular Genetic Diagnosis with Next-Generation Sequencing in 46,XY Disorders of Sex Development Cases: Efficiency and Cost Assessment. Horm Res Paediatr 2017; 87:81-87. [PMID: 27898418 DOI: 10.1159/000452995] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/02/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND/AIM The aim of this study was to use targeted next-generation sequencing (TNGS) including all known genes associated with 46,XY disorders of sex development (DSD) for a fast molecular genetic diagnosis. METHODS Twenty pediatric patients were recruited, and 56 genes related to 46,XY DSD were sequenced using TNGS. The time elapsed between initial appointment and final diagnosis as well as the mean expenditure was determined. RESULTS A total of 9 (45%) mutations in 4 different genes were identified. Mutations in the HSD17B3 gene were observed in 6 (30%) patients. A heterozygous mutation in WT1 gene and a hemizygous mutation in SRY gene were detected in patients with gonadal dysgenesis. One patient had a homozygous mutation in LHCGR gene. Prior to the molecular diagnosis, the mean number of clinical visits, time elapsed until diagnosis, and expenditure were 27.4 ± 14.6 visits, 5.9 ± 4.1 years per patient, and USD 2,142 ± 1,038, respectively. With TNGS, time elapsed until diagnosis was significantly reduced (3 days), and expenditure per patient was only one third of the conventional approach (USD 761). CONCLUSIONS TNGS is an efficient, rapid, and cost-effective technique for mutation detection in 46,XY DSD.
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Affiliation(s)
- Samim Özen
- Department of Pediatric Endocrinology, School of Medicine, Ege University, Izmir, Turkey
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323
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Adam MP, Vilain E. Emerging issues in disorders/differences of sex development (DSD). AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:249-252. [PMID: 28577349 DOI: 10.1002/ajmg.c.31564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 05/01/2017] [Indexed: 11/10/2022]
Abstract
Disorders/Differences of Sex Development (DSD), as defined by the 2006 Consensus Statement, are "congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical." They represent a spectrum of chronic medical conditions collectively affecting about 1% of the population and are associated with increased risk of infertility, cancer, and psychosocial distress. Clinical management in DSD is subject to multiple controversies about gender assignment, the timing and appropriateness of genital surgery and the approach to disclosure. There is dissent within and between stakeholders (healthcare providers, advocacy groups, families) regarding what constitutes optimal care. This special issue investigates the progress made as well as the uncertainties remaining a decade after the consensus statement and the gaps to be filled by future research and improved clinical practice. It discusses the increasing intricacy of genetic variant interpretation in the era of next-generation sequencing and the associated complexity of phenotypic variability. The issue tackles ethical dilemmas and the complicated decision-making process of assignment of sex of rearing at birth in cases of 5-alpha reductase type 2 deficiency, surveys delivery of clinical services in the United States, discusses challenges of interdisciplinary care and of educating patients and parents about DSD,and reviews the factors predisposing to gonadal tumor and their consequences on clinical management.
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Affiliation(s)
- Margaret P Adam
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Eric Vilain
- Departments of Human Genetics, Urology, and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
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Sandberg DE, Gardner M, Callens N, Mazur T. Interdisciplinary care in disorders/differences of sex development (DSD): The psychosocial component of the DSD-Translational research network. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:279-292. [PMID: 28574671 DOI: 10.1002/ajmg.c.31561] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 01/28/2023]
Abstract
Scientific discovery and clinical management strategies for Disorders/Differences of Sex Development (DSD) have advanced in recent years. The 2006 Consensus Statement on Management of Intersex Disorders stated that a mental health component to care is integral to promote positive adaptation, yet the parameters of this element have not been described. The objective of this paper is threefold: to describe the psychosocial screening protocol adopted by the clinical centers of the DSD-Translational Research Network; to summarize psychosocial data collected at 1 of the 10 network sites; and to suggest how systematic behavioral health screenings can be employed to tailor care in DSD that results in better health and quality of life outcomes. Steps taken in developing the largely "noncategorical" screening protocol are described. These preliminary findings suggest that DSD, as one category of pediatric chronic conditions, is not associated with marked disturbances of psychosocial adaptation, either for the family or the child; however, screening frequently uncovered "risk factors" for individual families or patients that can potentially be addressed in the context of ongoing clinical care. Administration of the DSD-TRN psychosocial screening protocol was demonstrated to be feasible in the context of interdisciplinary team care and was acceptable to families on a longitudinal basis. The ultimate value of systematic screening will be demonstrated through a tailoring of psychosocial, medical and surgical services, based on this information that enhances the quality of patient and family-centered care and subsequent outcomes.
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Affiliation(s)
- David E Sandberg
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Melissa Gardner
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nina Callens
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.,Faculty of Arts and Philosophy, Department of Languages and Cultures, Center for Research on Culture and Gender, Ghent University, Ghent, Belgium
| | - Tom Mazur
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, New York
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325
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Yatsenko SA, Witchel SF. Genetic approach to ambiguous genitalia and disorders of sex development: What clinicians need to know. Semin Perinatol 2017; 41:232-243. [PMID: 28545654 DOI: 10.1053/j.semperi.2017.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Genetic tools such as microarray and next-generation sequencing have initiated a new era for the diagnosis and management of patients with disorders of sex development (DSDs). These tools supplement the traditional approach to the evaluation and care of infants, children, and adolescents with DSDs. These tests can detect genetic variations known to be associated with DSDs, discover novel genetic variants, and elucidate novel mechanisms of gene regulation. Herein, we discuss these tests and their role in the management of patients with DSDs.
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Affiliation(s)
- Svetlana A Yatsenko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA; Department of Pathology, University of Pittsburgh, School of Medicine, Pittsburgh, PA; Department of Human Genetics, University of Pittsburgh, School of Public Health, Pittsburgh, PA
| | - Selma Feldman Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224.
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326
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Campo-Engelstein L, Chen D, Baratz AB, Johnson EK, Finlayson C. The Ethics of Fertility Preservation for Pediatric Patients With Differences (Disorders) of Sex Development. J Endocr Soc 2017; 1:638-645. [PMID: 28944319 PMCID: PMC5607629 DOI: 10.1210/js.2017-00110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Differences (disorders) of sex development are diverse conditions with variations in chromosomal, gonadal, and/or genital development. Fertility potential in this population is variable. Recent investigations into fertility potential in those previously thought to be infertile suggest that the majority may have fertility potential through experimental protocols. Fertility preservation may be more successful if pursued in childhood. As fertility research and techniques advance, it is important to carefully consider pediatric ethical issues specific to this population, including gonadectomy, consent/assent, experimental treatment and false hope, cost and insurance coverage, genetic transmission to offspring, and gender dysphoria.
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Affiliation(s)
- Lisa Campo-Engelstein
- Alden March Bioethics Institute, Department of Obstetrics and Gynecology, Albany Medical College, Albany, New York 12208
| | - Diane Chen
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Arlene B Baratz
- Division of Breast Imaging, West Penn Allegheny Health System, Temple University School of Medicine, Pittsburgh, Pennsylvania 15212
| | - Emilie K Johnson
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Courtney Finlayson
- Division of Pediatric Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
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327
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Bakula DM, Mullins AJ, Sharkey CM, Wolfe-Christensen C, Mullins LL, Wisniewski AB. Gender identity outcomes in children with disorders/differences of sex development: Predictive factors. Semin Perinatol 2017; 41:214-217. [PMID: 28478086 DOI: 10.1053/j.semperi.2017.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disorders/differences of sex development (DSD) comprise multiple congenital conditions in which chromosomal, gonadal, and/or anatomical sex are discordant. The prediction of future gender identity (i.e., self-identifying as male, female, or other) in children with DSD can be imprecise, and current knowledge about the development of gender identity in people with, and without DSD, is limited. However, sex of rearing is the strongest predictor of gender identity for the majority of individuals with various DSD conditions. When making decisions regarding sex of rearing biological factors (e.g., possession of a Y chromosome, degree and duration of pre- and postnatal androgen exposure, phenotypic presentation of the external genitalia, and fertility potential), social and cultural factors, as well as quality of life should be considered. Information on gender identity outcomes across a range of DSD diagnoses is presented to aid in sex of rearing assignment.
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Affiliation(s)
- Dana M Bakula
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074.
| | - Alexandria J Mullins
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | - Christina M Sharkey
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | | | - Larry L Mullins
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | - Amy B Wisniewski
- Department of Pediatric Urology, Genitourinary Program, Cook Children's Hospital, Fort Worth, TX
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328
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Délot EC, Papp JC, Sandberg DE, Vilain E. Genetics of Disorders of Sex Development: The DSD-TRN Experience. Endocrinol Metab Clin North Am 2017; 46:519-537. [PMID: 28476235 PMCID: PMC5714504 DOI: 10.1016/j.ecl.2017.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although many next-generation sequencing platforms are being created around the world, implementation is facing multiple hurdles. A strong hurdle to the full adherence of clinical teams to the Disorders of Sex Development Translational Research Network (DSD-TRN) guidelines for standardization of reporting and practice is the current lack of integration of the standardized clinical forms into the various electronic medical records at different sites. Time allocated to research is also limited. In spite of these hurdles, genetic information for half the enrolled patients is already available in the DSD-TRN registry, and early results demonstrate the value of such an infrastructure.
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Affiliation(s)
- Emmanuèle C Délot
- Departments of Human Genetics and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Room 5301A, 695 Charles East Young Drive South, Los Angeles, CA 90095, USA.
| | - Jeanette C Papp
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Room 5506, 695 Charles East Young Drive South, Los Angeles, CA 90095, USA
| | - David E Sandberg
- Division of Pediatric Psychology, Department of Pediatrics & Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Eric Vilain
- Departments of Human Genetics, Urology, and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Room 4554B, 695 Charles East Young Drive South, Los Angeles, CA 90095, USA
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329
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Chen MJ, McCann-Crosby B, Gunn S, Georgiadis P, Placencia F, Mann D, Axelrad M, Karaviti L, McCullough LB. Fluidity models in ancient Greece and current practices of sex assignment. Semin Perinatol 2017; 41:206-213. [PMID: 28478088 PMCID: PMC5950726 DOI: 10.1053/j.semperi.2017.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Disorders of sexual differentiation such as androgen insensitivity and gonadal dysgenesis can involve an intrinsic fluidity at different levels, from the anatomical and biological to the social (gender) that must be considered in the context of social constraints. Sex assignment models based on George Engel's biopsychosocial aspects model of biology accept fluidity of gender as a central concept and therefore help establish expectations within the uncertainty of sex assignment and anticipate potential changes. The biology underlying the fluidity inherent to these disorders should be presented to parents at diagnosis, an approach that the gender medicine field should embrace as good practice. Greek mythology provides many accepted archetypes of change, and the ancient Greek appreciation of metamorphosis can be used as context with these patients. Our goal is to inform expertise and optimal approaches, knowing that this fluidity may eventually necessitate sex reassignment. Physicians should provide sex assignment education based on different components of sexual differentiation, prepare parents for future hormone-triggered changes in their children, and establish a sex-assignment algorithm.
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Affiliation(s)
- Min-Jye Chen
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
| | - Bonnie McCann-Crosby
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030.
| | - Sheila Gunn
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
| | - Paraskevi Georgiadis
- Section of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Frank Placencia
- Section of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - David Mann
- Department of Anesthesiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Marni Axelrad
- Section of Psychology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - L.P Karaviti
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
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330
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Greenberg JA. Legal, ethical, and human rights considerations for physicians treating children with atypical or ambiguous genitalia. Semin Perinatol 2017; 41:252-255. [PMID: 28478089 DOI: 10.1053/j.semperi.2017.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Some governments, human rights organizations, intersex organizations, and doctors have called for a moratorium on genital and gonadal surgeries for infants born with atypical or ambiguous genitalia. Moratorium supporters believe that the surgeries carry physical and emotional risks, the psychosocial benefits of these procedures have not been proven, and the surgeries violate the patients׳ fundamental human rights if they are performed before these patients can provide informed consent. Given these calls for a moratorium, treatment teams must determine how to treat their patients and how to counsel their patients׳ parents. This article examines the treatment teams׳ ethical and legal responsibilities and provides advice for treatment teams to follow that will protect their patients and their practices.
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Affiliation(s)
- Julie A Greenberg
- Thomas Jefferson School of Law, 1155 Island Avenue, San Diego, CA 92101.
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331
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Sandberg DE, Pasterski V, Callens N. Introduction to the Special Section: Disorders of Sex Development. J Pediatr Psychol 2017; 42:487-495. [PMID: 28499017 PMCID: PMC5896587 DOI: 10.1093/jpepsy/jsx065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Nina Callens
- Department of Pediatrics, University of Michigan Medical School
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332
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Rolston AM, Gardner M, van Leeuwen K, Mohnach L, Keegan C, Délot E, Vilain E, Sandberg DE. Disorders of sex development (DSD): Clinical service delivery in the United States. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:268-278. [PMID: 28557237 DOI: 10.1002/ajmg.c.31558] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/21/2017] [Accepted: 03/29/2017] [Indexed: 11/06/2022]
Abstract
Following the principles of care recommended in the 2006 Consensus Statement on Disorders of Sex Development (DSD), along with input from representatives of peer support and advocacy groups, this study surveyed DSD clinical management practices at healthcare facilities in the United States. DSD are congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical. Facilities providing care for patients with DSD were targeted for participation. Specialty providers completed a survey with questions in six broad categories: Institution Information, Nomenclature and Care Guidelines, Interdisciplinary Services, Staff and Community Education, DSD Management, and Research. Twenty-two of 36 targeted sites (61%) participated. Differences were observed between sites with regard to what conditions were considered to be DSD. All sites reported some degree of involvement of pediatric urology and/or surgery and pediatric endocrinology in the care of DSD patients. Gynecology and neonatology were most frequently not represented. Wide variation was observed across sites in continuing education standards, obtaining informed consent for clinical procedures, and in specific clinical management practices. This survey is the first to assess DSD clinical management practices in the United States. The findings establish a baseline of current practices against which providers delivering care to these patients and their families can benchmark their efforts. Such surveys also provide a practical framework for collaboration in identifying opportunities for change that enhance health and quality of life outcomes for patients and families affected by DSD.
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Affiliation(s)
- Aimee M Rolston
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Lauren Mohnach
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Catherine Keegan
- Division of Genetics, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Emmanuèle Délot
- Department of Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David E Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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333
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Gynecological challenges in the diagnosis and care of patients with DSD: The role of the obstetrician gynecologist in the multidisciplinary approach to the patient. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:300-303. [DOI: 10.1002/ajmg.c.31557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/13/2017] [Accepted: 03/27/2017] [Indexed: 11/07/2022]
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334
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Pyle LC, Nathanson KL. A practical guide for evaluating gonadal germ cell tumor predisposition in differences of sex development. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:304-314. [PMID: 28544305 DOI: 10.1002/ajmg.c.31562] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 01/16/2023]
Abstract
Differences of Sex Development (DSD) includes a wide spectrum of etiologies and phenotypes. A subset of individuals with DSDs are predisposed to gonadal germ cell tumor (GCT). In this setting, GCT risk varies widely, depending on the DSD molecular etiology and penetrance. Prognostication based on molecular diagnosis remains challenging, as natural history data specific to recently identified molecular causes of DSD is lacking. In this review, we provide a framework for the clinical geneticist to consider GCT tumor risk in the patient with DSD. We discuss germ cell development and etiology of GCT growth, along with parameters to consider when recommending prophylactic gonadectomy including fertility, hormonal output, and malignant GTC treatment outcomes. Shortly after the 2006 reorganization of DSD nomenclature, literature reviews of natural history publications stratified GCT risk by a chromosomal, pathological, and hormonal taxonomy. Our 2017 literature review reveals a larger body of publications. However, the broad DSD GCT risk stratification within the 2006 taxonomy remains stable. We discuss precise GCT risk assessment for specific diagnoses, including androgen insensitivity, Smith-Lemli-Opitz, and 46,XY with MAP3K1 mutations and gonadal dysgenesis, as examples. We also examine the GCT risk in non-DSD syndromes, in addition to the cancer risks in DSD patients with dimorphic gonads and genitalia. This review is intended to provide a nuanced assessment of relative germ cell tumor risk in the DSD patient, including modern precise molecular diagnosis, for use by the clinical geneticist.
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Affiliation(s)
- Louise C Pyle
- Translational Medicine/Human Genetics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Katherine L Nathanson
- Translational Medicine/Human Genetics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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335
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The importance of communicating histories of gender assignment and reassignment to genetic laboratories. Genet Med 2017. [DOI: 10.1038/gim.2017.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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336
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Huang H, Wang C, Tian Q. Gonadal tumour risk in 292 phenotypic female patients with disorders of sex development containing Y chromosome or Y-derived sequence. Clin Endocrinol (Oxf) 2017; 86:621-627. [PMID: 27862157 DOI: 10.1111/cen.13255] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/22/2016] [Accepted: 10/08/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Phenotypic female disorders of sex development (DSD) patients with Y chromosome or Y-derived sequence have an increased risk of gonadal germ cell tumours (GCTs). The objective of the study was to evaluate tumour risk of DSD, summarize the clinical characteristics of patients with GCTs and propose management suggestions. METHODS Medical records of 292 patients diagnosed DSD and undergoing bilateral gonadectomy at Peking Union Medical College Hospital from January 1996 to March 2016 were retrospectively reviewed. Tumour histopathological types, risks and clinical characteristics were evaluated. RESULTS The tumours in DSD included gonadoblastoma, seminoma, dysgerminoma, Sertoli cell tumour, yolk sac tumour and choriocarcinoma. The overall GCTs risk was 15·41% and 46, XY pure gonadal dysgenesis (46, XY PGD) carried the highest risk up to 23·33%, followed by complete androgen insensitivity syndrome (CAIS). The risk of mixed gonadal dysgenesis (GD) or 46, XY 17 alpha-hydroxylase/17, 20-lyase deficiency (46, XY 17 OHD) was <10%, and no tumour was found in five testis regression patients. The ages (years) of tumour diagnosed ranged from 11 to 29 [18 (15, 21) years]. The median age of androgen insensitivity syndrome (AIS) with tumours was comparatively late [19 (18, 24) years], while GCTs occurred during adolescence in 46, XY PGD [17 (15, 20) years] and mixed GD [15 (15, 17) years]. Sex hormone levels were generally unaffected by gonadal GCTs. The positive tumour marker rate before surgery was 58·82% (10/17). Elevated lactate dehydrogenase (LDH) was observed in six cases with dysgerminoma/seminoma. Remarkably elevated α-fetoprotein (AFP) or human chorionic gonadotropin (hCG) was seen in cases with yolk sac tumour or choriocarcinoma, respectively. Mild hyperandrogenism was observed in seven cases with GCTs. Fourteen of 17 pelvic masses found before operation was later proved malignant. CONCLUSION Disorders of sex development patients with Y chromosome materials have a significantly increased risk of GCTs. Gonadoblastoma and dysgerminoma/seminoma are the most prevalent GCTs and 46, XY PGD carries the highest tumour presence and malignancy risk. AIS could postpone bilateral gonadectomy until or after adolescence, while others with streak gonads should undergo surgery as soon as diagnosis. Specific serum tumour markers could be used in predicting GCTs and monitoring. Optimal care and close follow-up are required.
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Affiliation(s)
- He Huang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunqing Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qinjie Tian
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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337
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Kourime M, Bryce J, Jiang J, Nixon R, Rodie M, Ahmed S. An assessment of the quality of the I-DSD and the I-CAH registries - international registries for rare conditions affecting sex development. Orphanet J Rare Dis 2017; 12:56. [PMID: 28320446 PMCID: PMC5360059 DOI: 10.1186/s13023-017-0603-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/27/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND With the proliferation of rare disease registries, there is a need for registries to undergo an assessment of their quality against agreed standards to ensure their long-term sustainability and acceptability.This study was performed to evaluate the I-DSD and I-CAH Registries and identify their strengths and weaknesses. METHODS The design and operational aspects of the registries were evaluated against published quality indicators. Additional criteria included the level of activity, international acceptability of the registries and their use for research. RESULTS The design of the I-DSD and I-CAH Registries provides them with the ability to perform multiple studies and meet the standards for data elements, data sources and eligibility criteria. The registries follow the standards for data security, governance, ethical and legal issues, sustainability and communication of activities. The data have a high degree of validity, consistency and accuracy and the completeness is maximal for specific conditions such as androgen insensitivity syndrome and congenital adrenal hyperplasia. In terms of research output, the external validity is strong but the wide variety of cases needs further review. The internal validity of data was condition specific and highest for conditions such as congenital adrenal hyperplasia. The shift of the registry from a European registry to an international registry and the creation of a discrete but linked CAH registry increased the number of users and stakeholders as well as the international acceptability of both registries. CONCLUSIONS The I-DSD and I-CAH registries comply with the standards set by expert organisations. Recent modifications in their operation have allowed the registries to increase their user acceptability.
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Affiliation(s)
- M. Kourime
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
- School of Medicine and Pharmacy, University of Hassan II, Tarik Ibnou Ziad Road, Casablanca, 20250 Morocco
| | - J. Bryce
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
| | - J. Jiang
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
| | - R. Nixon
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
| | - M. Rodie
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
| | - S.F. Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital For Children, Office Block, 1345 Govan Road, Glasgow, G51 4TF UK
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338
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Sweeting H, Maycock MW, Walker L, Hunt K. Public challenge and endorsement of sex category ambiguity in online debate: 'The sooner people stop thinking that gender is a matter of choice the better'. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:380-396. [PMID: 27859354 PMCID: PMC5363354 DOI: 10.1111/1467-9566.12490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Despite academic feminist debate over several decades, the binary nature of sex as a (perhaps the) primary social classification is often taken for granted, as is the assumption that individuals can be unproblematically assigned a biological sex at birth. This article presents analysis of online debate on the BBC news website in November 2013, comprising 864 readers' responses to an article entitled 'Germany allows 'indeterminate' gender at birth'. It explores how discourse reflecting Western essentialist beliefs about people having one sex or 'the other' is maintained in debates conducted in this online public space. Comments were coded thematically and are presented under five sub-headings: overall evaluation of the German law; discussing and disputing statistics and 'facts'; binary categorisations; religion and politics; and 'conversations' and threads. Although for many the mapping of binary sex onto gender was unquestionable, this view was strongly disputed by commentators who questioned the meanings of 'natural' and 'normal', raised the possibility of removing societal binary male-female distinctions or saw maleness-femaleness as a continuum. While recognising that online commentators are anonymous and can control their self-presentation, this animated discussion suggests that social classifications as male or female, even if questioned, remain fundamental in public debate in the early 21st century.
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Affiliation(s)
- Helen Sweeting
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowScotland
| | | | - Laura Walker
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowScotland
| | - Kate Hunt
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowScotland
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339
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- Division of Gender, Sexuality, and Health, New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University , New York, New York
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340
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Sanders C, Edwards Z, Keegan K. Exploring stakeholder experiences of interprofessional teamwork in sex development outpatient clinics. J Interprof Care 2017; 31:376-385. [DOI: 10.1080/13561820.2016.1272559] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Caroline Sanders
- Urology Department, Alder Hey Children’s Hospital, Liverpool, UK
| | - Zoe Edwards
- Psychology Department, Alder Hey Children’s Hospital, Liverpool, UK
| | - Kimberley Keegan
- Psychology Department, Alder Hey Children’s Hospital, Liverpool, UK
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341
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Hughes IA. Commentary to "Prospective assessment of cosmesis before and after genital surgery". J Pediatr Urol 2017; 13:30-31. [PMID: 28089296 DOI: 10.1016/j.jpurol.2016.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Ieuan A Hughes
- Emeritus Professor of Paediatrics, University of Cambridge, Cambridge, UK.
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342
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Bashamboo A, McElreavey K. Mechanism of Sex Determination in Humans: Insights from Disorders of Sex Development. Sex Dev 2016; 10:313-325. [DOI: 10.1159/000452637] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 12/13/2022] Open
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343
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Baratz AB. Re: "Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?". J Pediatr Urol 2016; 12:442-443. [PMID: 27697469 DOI: 10.1016/j.jpurol.2016.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 11/19/2022]
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344
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Kyriakou A, Dessens A, Bryce J, Iotova V, Juul A, Krawczynski M, Nordenskjöld A, Rozas M, Sanders C, Hiort O, Ahmed SF. Current models of care for disorders of sex development - results from an International survey of specialist centres. Orphanet J Rare Dis 2016; 11:155. [PMID: 27871307 PMCID: PMC5117601 DOI: 10.1186/s13023-016-0534-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/07/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND To explore the current models of practice in centres delivering specialist care for children with disorders of sex development (DSD), an international survey of 124 clinicians, identified through DSDnet and the I-DSD Registry, was performed in the last quarter of 2014. RESULTS A total of 78 (63 %) clinicians, in 75 centres, from 38 countries responded to the survey. A formal national network for managing DSD was reported to exist in 12 (32 %) countries. The paediatric specialists routinely involved in the initial evaluation of a newborn included: endocrinologist (99 %), surgeon/urologist (95 %), radiologist (93 %), neonatologist (91 %), clinical geneticist (81 %) and clinical psychologist (69 %). A team consisting of paediatric specialists in endocrinology, surgery/urology, clinical psychology, and nursing was only possible in 31 (41 %) centres. Of the 75 centres, 26 (35 %) kept only a local DSD registry and 40 (53 %) shared their data in a multicentre DSD registry. Attendance in local, national and international DSD-related educational programs was reported by 69, 78 and 84 % clinicians, respectively. Participation in audits/quality improvement exercises in DSD care was reported by 14 (19 %) centres. In addition to complex biochemistry and molecular genetic investigations, 40 clinicians (51 %) also had access to next generation sequencing. A genetic test was reported to be more preferable than biochemical tests for diagnosing 5-alpha reductase deficiency and 17-beta hydroxysteroid dehydrogenase 3 deficiency by 50 and 55 % clinicians, respectively. CONCLUSION DSD centres report a high level of interaction at an international level, have access to specialist staff and are increasingly relying on molecular genetics for routine diagnostics. The quality of care provided by these centres locally requires further exploration.
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Affiliation(s)
- Andreas Kyriakou
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Zone 1, Office Block, RHC & QEUH Campus, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Arianne Dessens
- Department of Child and Adolescent Psychiatry, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jillian Bryce
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Zone 1, Office Block, RHC & QEUH Campus, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Violeta Iotova
- Department of Paediatrics, Medical University of Varna, Varna, Bulgaria
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maciej Krawczynski
- Department of Medical Genetics, Poznan University of Medical Science, Poznań, Poland
| | - Agneta Nordenskjöld
- Paediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Marta Rozas
- GrApSIA (Grupo de Apoyo al Síndrome de Insensibilidad a los Andrógenos), Barcelona, Spain
| | - Caroline Sanders
- University of Northern British Columbia, Canada & Adjunct Alder Hey Children Hospital, NHS Trust UK, Prince George, Canada
| | - Olaf Hiort
- Division of Experimental Paediatric Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Zone 1, Office Block, RHC & QEUH Campus, 1345 Govan Road, Glasgow, G51 4TF, UK
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Presence of Germ Cells in Disorders of Sex Development: Implications for Fertility Potential and Preservation. J Urol 2016; 197:937-943. [PMID: 27840018 DOI: 10.1016/j.juro.2016.08.108] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE We sought to determine the presence of germ cells in the gonads of patients with disorders of sex development to establish whether preservation of germ cells for future fertility potential is possible. We hypothesized that germ cells are present but vary by age and diagnosis. MATERIALS AND METHODS We reviewed histology from patients with disorders of sex development who underwent gonadectomy/biopsy from 2002 to 2014 at a single institution for pathological classification of the gonad, composition of gonadal stroma and germ cell presence. RESULTS A total of 44 patients were identified and germ cells were present in 68%. The presence and average number of germ cells per mm2 were analyzed by gonad type and diagnosis. By gonad type all ovotestes, most testes, ovaries and dysgenetic testes, and 15% of streak gonads had germ cells present. By diagnosis germ cells were present in all patients with complete androgen insensitivity syndrome, Denys-Drash syndrome, SRY mutation, mixed gonadal dysgenesis, ovotesticular conditions and StAR (steroid acute regulatory protein) deficiency, in some patients with persistent müllerian duct syndrome, XO/XY Turner syndrome and disorders of sex development not otherwise specified, and in none with complete or partial gonadal dysgenesis. Germ cells were present in the gonads of 88% of patients 0 to 3 years old, 50% of those 4 to 11 years old and 43% of those older than 12 years. CONCLUSIONS Germ cells were present in the majority of our cohort and the presence decreased with age. This novel, fertility driven evaluation of germ cell quantity in a variety of disorders of sex development suggests that fertility potential may be greater than previously thought. Further studies must be done to evaluate a larger population and examine germ cell quality to determine the viability of these germ cells.
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346
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Fisher AD, Ristori J, Fanni E, Castellini G, Forti G, Maggi M. Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma. J Endocrinol Invest 2016; 39:1207-1224. [PMID: 27287420 DOI: 10.1007/s40618-016-0482-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development. AIMS (1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis. METHODS A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors' expertise. RESULTS A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD. CONCLUSIONS Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.
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Affiliation(s)
- A D Fisher
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - J Ristori
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - E Fanni
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Castellini
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
- Psychiatric Unit, Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - G Forti
- Endocrine Unit, "Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies" (DENOThe), Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Careggi Hospital, Florence, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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347
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Finlayson C, Johnson EK, Chen D, Dabrowski E, Gosiengfiao Y, Campo-Engelstein L, Rosoklija I, Jacobson J, Shnorhavorian M, Pavone ME, Moravek MB, Bonifacio HJ, Simons L, Hudson J, Fechner PY, Gomez-Lobo V, Kadakia R, Shurba A, Rowell E, Woodruff TK. Proceedings of the Working Group Session on Fertility Preservation for Individuals with Gender and Sex Diversity. Transgend Health 2016; 1:99-107. [PMID: 28111635 PMCID: PMC5243122 DOI: 10.1089/trgh.2016.0008] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Children and adolescents with gender and sex diversity include (1) gender-nonconforming and transgender individuals for whom gender identity or expression are incongruent with birth-assigned sex (heretofore, transgender) and (2) individuals who have differences in sex development (DSD). Although these are largely disparate groups, there is overlap in the medical expertise necessary to care for individuals with both gender and sex diversity. In addition, both groups face potential infertility or sterility as a result of desired medical and surgical therapies. The Ann & Robert H. Lurie Children's Hospital of Chicago (Lurie Children's) gender and sex development program (GSDP) provides specialized multidisciplinary care for both transgender and DSD patients. In response to patient concerns that recommended medical treatments have the potential to affect fertility, the Lurie Children's GSDP team partnered with experts from the Oncofertility Consortium at Northwestern University to expand fertility preservation options to gender and sex diverse youth. This article summarizes the results of a meeting of experts across this field at the annual Oncofertility Consortium conference with thoughts on next steps toward a unified protocol for this patient group.
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Affiliation(s)
- Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.; Department of Urology, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Diane Chen
- Division of Adolescent Medicine, Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.; Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine Chicago, Chicago, Illinois
| | - Elizabeth Dabrowski
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yasmin Gosiengfiao
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.; Division of Hematology/Oncology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lisa Campo-Engelstein
- Department of Obstetrics and Gynecology, Alden March Bioethics Institute, Albany Medical College, Albany, New York
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jill Jacobson
- Division of Endocrinology, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Margarett Shnorhavorian
- Division of Urology, Seattle Children's Hospital, Department of Urology, University of Washington Seattle, Seattle, Washington
| | - Mary Ellen Pavone
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Herbert J Bonifacio
- Division of Adolescent Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lisa Simons
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.; Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Janella Hudson
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Patricia Y Fechner
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington Seattle, Seattle, Washington
| | - Veronica Gomez-Lobo
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center/Children's National Health System, Washington, District of Columbia
| | - Rachel Kadakia
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Angela Shurba
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erin Rowell
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Teresa K Woodruff
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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348
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Pearce M, DeMartino L, McMahon R, Hamel R, Maloney B, Stansfield DM, McGrath EC, Occhionero A, Gearhart A, Caggana M, Tavakoli NP. Newborn screening for congenital adrenal hyperplasia in New York State. Mol Genet Metab Rep 2016; 7:1-7. [PMID: 27331001 PMCID: PMC4908061 DOI: 10.1016/j.ymgmr.2016.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/19/2016] [Accepted: 02/20/2016] [Indexed: 11/17/2022] Open
Abstract
From 2007 to 2014 the New York State (NYS) Newborn Screening (NBS) program screened 2 million newborns for congenital adrenal hyperplasia (CAH). The data was analyzed to determine factors that affect 17α-hydroxyprogesterone levels and assist in developing algorithm changes that would improve the positive predictive value of the methodology being used. The concentration of 17-OHP in dried blood spots was measured using the AutoDELFIA Neonatal 17-OHP kit (Perkin Elmer, Turku, Finland). During the 8 year period of this study 2476 babies were referred, 105 babies were diagnosed with CAH (90 with the salt-wasting (SW), 8 with simple virilizing (SV), 5 with non-classical CAH, and 2 with another enzyme deficiency) and, 14 with possible CAH. Three false negative cases with SV-CAH were reported to the program. Of the total 108 known cases, 74 (69%) infants were detected by newborn screening in the absence of clinical information, or, known family history. The incidence of CAH in NYS is 1 in 18,170 with a ratio of SW to SV of 8.2:1. The incidence of CAH is lower in Black infants than in White, Hispanic and Asian infants. Despite a lower mean birth weight, female infants have a lower mean 17-OHP value than male infants and are under-represented in the referred category. As per other NBS programs the false positive rate is exacerbated by prematurity/low birth weight and by over-early specimen collection.
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Affiliation(s)
- Melissa Pearce
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Lenore DeMartino
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rebecca McMahon
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rhonda Hamel
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Breanne Maloney
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | | | - Emily C McGrath
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Amanda Occhionero
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Adam Gearhart
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Michele Caggana
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Norma P Tavakoli
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Biomedical Sciences, School of Public Health, State University of New York, Albany, NY, USA
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349
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De Paula GB, Barros BA, Carpini S, Tincani BJ, Mazzola TN, Sanches Guaragna M, Piveta CSDC, de Oliveira LC, Andrade JGR, Guaragna-Filho G, Barbieri PP, Ferreira NM, Miranda ML, Gonçalves EM, Morcillo AM, Viguetti-Campos NL, Lemos-Marini SHV, Silva RBDP, Marques-de-Faria AP, De Mello MP, Maciel-Guerra AT, Guerra-Junior G. 408 Cases of Genital Ambiguity Followed by Single Multidisciplinary Team during 23 Years: Etiologic Diagnosis and Sex of Rearing. Int J Endocrinol 2016; 2016:4963574. [PMID: 28018429 PMCID: PMC5149677 DOI: 10.1155/2016/4963574] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. To evaluate diagnosis, age of referral, karyotype, and sex of rearing of cases with disorders of sex development (DSD) with ambiguous genitalia. Methods. Retrospective study during 23 years at outpatient clinic of a referral center. Results. There were 408 cases; 250 (61.3%) were 46,XY and 124 (30.4%) 46,XX and 34 (8.3%) had sex chromosomes abnormalities. 189 (46.3%) had 46,XY testicular DSD, 105 (25.7%) 46,XX ovarian DSD, 95 (23.3%) disorders of gonadal development (DGD), and 19 (4.7%) complex malformations. The main etiology of 46,XX ovarian DSD was salt-wasting 21-hydroxylase deficiency. In 46,XX and 46,XY groups, other malformations were observed. In the DGD group, 46,XY partial gonadal dysgenesis, mixed gonadal dysgenesis, and ovotesticular DSD were more frequent. Low birth weight was observed in 42 cases of idiopathic 46,XY testicular DSD. The average age at diagnosis was 31.7 months. The final sex of rearing was male in 238 cases and female in 170. Only 6.6% (27 cases) needed sex reassignment. Conclusions. In this large DSD sample with ambiguous genitalia, the 46,XY karyotype was the most frequent; in turn, congenital adrenal hyperplasia was the most frequent etiology. Malformations associated with DSD were common in all groups and low birth weight was associated with idiopathic 46,XY testicular DSD.
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Affiliation(s)
- Georgette Beatriz De Paula
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Beatriz Amstalden Barros
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Stela Carpini
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Pediatrics, FCM, UNICAMP, Campinas, SP, Brazil
| | - Bruna Jordan Tincani
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Tais Nitsch Mazzola
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering (CBMEG), UNICAMP, Campinas, SP, Brazil
| | - Mara Sanches Guaragna
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering (CBMEG), UNICAMP, Campinas, SP, Brazil
| | - Cristiane Santos da Cruz Piveta
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering (CBMEG), UNICAMP, Campinas, SP, Brazil
| | - Laurione Candido de Oliveira
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Laboratory of Clinical Pathology, Clinical Hospital, FCM, UNICAMP, Campinas, SP, Brazil
| | - Juliana Gabriel Ribeiro Andrade
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Guilherme Guaragna-Filho
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Pedro Perez Barbieri
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
| | - Nathalia Montibeler Ferreira
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
| | - Marcio Lopes Miranda
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Pediatric Surgery, Department of Surgery, FCM, UNICAMP, Campinas, SP, Brazil
| | - Ezequiel Moreira Gonçalves
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
| | - Andre Moreno Morcillo
- Department of Pediatrics, FCM, UNICAMP, Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
| | | | - Sofia Helena Valente Lemos-Marini
- Department of Pediatrics, FCM, UNICAMP, Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
| | - Roberto Benedito de Paiva Silva
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Antonia Paula Marques-de-Faria
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Medical Genetics, FCM, UNICAMP, Campinas, SP, Brazil
| | - Maricilda Palandi De Mello
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering (CBMEG), UNICAMP, Campinas, SP, Brazil
| | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Medical Genetics, FCM, UNICAMP, Campinas, SP, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, SP, Brazil
- Department of Pediatrics, FCM, UNICAMP, Campinas, SP, Brazil
- Growth and Development Laboratory, Center for Investigation in Pediatrics (CIPED), FCM, UNICAMP, Campinas, SP, Brazil
- *Gil Guerra-Junior:
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