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Del Can Sánchez DJ, Dueñas Disotuar S, Piñar Gutiérrez A, Japón Rodríguez MÁ, Olea Comas I, Déniz García A, Soto Moreno A, Mangas Cruz MÁ. Gender Incongruity in a Person with 46,XY and Complete Androgen Insensitivity Syndrome Raised as a Female. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:2353-2357. [PMID: 34786658 DOI: 10.1007/s10508-021-02183-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 05/22/2021] [Accepted: 10/09/2021] [Indexed: 06/13/2023]
Abstract
We present the case of a patient with female sex assignment at birth whose parents consulted with a pediatrician when the child was 12 years old, indicating that despite female sex assignment, she felt that she (henceforth "he") had a male gender identity and was gynephilic. Medical examination revealed a 46XY karyotype, a primary amenorrhea and an appropriate testosterone increase after HCG stimulation test. The patient was diagnosed then with a 46,XY disorder of sex development with androgen insensitivity syndrome, but then he missed subsequent appointments. At the age of 24, he resumed medical follow-up to reaffirm his male gender identity through sex reassignment surgery. His physical examination showed a Tanner stage III-IV breast development, vulva, clitoris, normal-sized vagina, absence of uterus and ovaries on transvaginal ultrasound, bilateral cryptorchidism on abdominal-pelvic MRI and osteoporosis on bone densitometry. The results of the blood tests were LH 24.5 mIU/mL [normal range, 1.7-8.6 mIU/mL for men] and testosterone 8.8 nmol/L [8.7-33 nmol/L]; conversely, FSH, estradiol, progesterone, and prolactin levels were normal. The molecular genetic analysis revealed an androgen receptor gene mutation associated with complete androgen insensitivity syndrome. At present, the patient has undergone bilateral orchiectomy and has initiated treatment with topical testosterone and bisphosphonates. We have yet to evaluate the effects and decide the best therapy taking into account that he has a male gender identity but complete androgen insensitivity syndrome.
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Affiliation(s)
- Diego Jesús Del Can Sánchez
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain.
| | - Suset Dueñas Disotuar
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Ana Piñar Gutiérrez
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | | | - Isabel Olea Comas
- Department of Diagnostic Imaging of the University Hospital Virgen del Rocío, Seville, Spain
| | - Alejandro Déniz García
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Alfonso Soto Moreno
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Miguel Ángel Mangas Cruz
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
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Ristori J, Cocchetti C, Romani A, Mazzoli F, Vignozzi L, Maggi M, Fisher AD. Brain Sex Differences Related to Gender Identity Development: Genes or Hormones? Int J Mol Sci 2020; 21:ijms21062123. [PMID: 32204531 PMCID: PMC7139786 DOI: 10.3390/ijms21062123] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/21/2020] [Accepted: 02/28/2020] [Indexed: 12/19/2022] Open
Abstract
The complex process of sexual differentiation is known to be influenced by biological and environmental determinants. The present review has the aim of summarizing the most relevant studies on the biological basis of sexual development, and in particular, it focuses on the impact of sex hormones and genetic background on the development of sexual differentiation and gender identity. The authors conducted a search of published studies on Medline (from January 1948 to December 2019). The evidence suggests that the sexual dimorphic brain could be the anatomical substrate of psychosexual development, on which gonadal hormones may have a shaping role during prenatal and pubertal periods. Additionally, according to several heritability studies, genetic components may have a role, but a promising candidate gene has not been identified. Even though growing evidence underlines the primary role of biological factors on psychosexual development, further studies are necessary to better explain their complex interactions.
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Affiliation(s)
- Jiska Ristori
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Carlotta Cocchetti
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Alessia Romani
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Francesca Mazzoli
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Linda Vignozzi
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Mario Maggi
- Endocrinology, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Alessandra Daphne Fisher
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
- Correspondence:
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Abstract
This article reviews the current literature characterizing potential factors associated with the etiologies of gender identity. The PubMed database was searched for all literature that assessed key elements affecting development of gender identity. Current models attribute gender identity etiology to endogenous biology along with prenatal androgen exposure. However, no genetic loci or specific neuroanatomic regions have been consistently identified as the single explanation for transgender identity. Although environment may play a role in gender expression, there are no data to suggest an exogenous explanation for the development of gender identity.
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Affiliation(s)
- Sira Korpaisarn
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston University School of Medicine, 720 Harrison Avenue, 8th Floor, Suite 8100, Boston, MA 02118, USA.
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, 275 7th Avenue, Suite 1505, New York, NY 10001, USA
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Deeb A, Khamis M, Sayed SA, Magdy Omar O, Odeh R, Ladjouze A, Ameri EA. Sex assignment practice in disorders of sexual differentiation: survey results from paediatric endocrinologists in the Arab region. J Pediatr Endocrinol Metab 2019; 32:75-82. [PMID: 30864373 DOI: 10.1515/jpem-2018-0323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 11/16/2018] [Indexed: 11/15/2022]
Abstract
Background Sex assignment is a major issue in disorders of sexual differentiation (DSD). Not all conditions of DSD have clear recommendations on assignment and timing of surgery. Reports about sex assignment practice and the influence of culture and religion in the Arab region are scarce. Methods A survey questionnaire was distributed to participants in a paediatric endocrinology conference. Four DSD cases were presented. Participants were asked to fill in their answers on sex assignment choice, reasons for the particular assignment, strength of own recommendation and timing of surgery based on their practice. The cases presented were severely virilised XX congenital adrenal hyperplasia (CAH), complete androgen insensitivity syndrome (CAIS), severely undervirilised 5α reductase deficiency (5α RD) and XX ovotesticular case. Results Eighty-five endocrinologists participated in the study. Eighty (97.5%) chose a female sex to assign for the XX CAH. For the CAIS, 64 (78%) chose a female sex. Seventy-one (86.5%) voted for a male sex for the XY case of 5α RD. Forty-seven (57%) and 35 (43%) chose a female and a male sex for the ovotesticular case, respectively. The majority indicated that their advice for sex assignment is based on strong recommendations for the CAH, CAIS and 5α RD patients but they were open to the parents' cultural and religious beliefs in their decision of the assignment for the ovotesticular case. Conclusions Practice in the Arab region appears to be in line with the international guidelines in the majority of DSD sex assignment and timing of surgery issues. However, culture and religious beliefs influence the practice in certain circumstances.
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Affiliation(s)
- Asma Deeb
- Paediatric Endocrinology Department, Mafraq Hospital, Abu Dhabi, UAE
| | - Maryam Khamis
- Paediatric Endocrinology Department, Mafraq Hospital, Abu Dhabi, UAE
| | - Shayma Al Sayed
- Paediatric Endocrinology and Diabetology Department, Alexandria University, Alexandria, Egypt
| | - Omneya Magdy Omar
- Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rasha Odeh
- Department of Paediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Asmahane Ladjouze
- Paediatric Department, Bab el Oued Teaching Hospital, Algiers, Algeria
| | - Elham Al Ameri
- Pediatric Endocrinology Department, Al Qassimi Hospital, Sharjah, UAE
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Nagaraja MR, Gubbala SP, Delphine Silvia CRW, Amanchy R. Molecular diagnostics of disorders of sexual development: an Indian survey and systems biology perspective. Syst Biol Reprod Med 2018; 65:105-120. [PMID: 30550360 DOI: 10.1080/19396368.2018.1549619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We aimed to survey the monogenic causes of disorders of sex development (DSD) and thereby its prevalence in India. This study revealed mutations resulting in androgen insensitivity syndrome, 5α-reductase type 2 deficiency, and gonadal dysgenesis were commonly reported. Intriguingly, AR deficits were the most prevalent (32 mutations) and of 11/26 missense mutations were in exons 4-8 (encoding ligand binding domain). The unique features of SRD5A2 defects were p.R246Q (most prevalent) and p.G196S could be mutational hotspots, dual gene defects (p.A596T in AR and p.G196S in SRD5A2) in a patient with hypospadias and novel 8 nucleotide deletion (exon 1) found in a patient with perineal hypospadias. Deficits in SRY, WT1, DHH, NR5A1, and DMRT1 caused 46,XY gonadal dysgenesis. Notably, mutations in AR, SRD5A2, MAMLD1, WT1, and MAP3K1 have led to hypospadias and only one CYP19A1 mutation caused aromatase deficiency was reported to date. Data mining from various databases has not only reinforced the role of well-established genes (e.g., SRY, WT1, DHH, NR5A1, DMRT1, AR, SRD5A2, MAMLD1) involved in DSD but also provided us 12 more potential candidate genes (ACVR1, AMHR2, CTNNB1, CYP11A1, CYP19A1, FGFR2, FGF9, PRKACA, PRKACG, SMAD9, TERT, ZFPM2), which benefit from a close association with the well-established genes involved in DSD and might be useful to screen owing to their direct gene-phenotype relationship or through direct functional interaction. As more genes have been revealed in relation to DSD, we believe ultimately it holds a better scenario for therapeutic regimen. Despite the advances in translational medicine, hospitals are yet to adopt genetic testing and counseling facilities in India that shall have potential impact on clinical diagnosis. Abbreviations: 5α-RD2: 5α-Reductase type 2; AIS: androgen insensitivity syndrome; AMH: antimullerian hormone; AMHR: antimullerian hormone receptor; AR: androgen receptor gene; CAH: congenital adrenal hyperplasia; CAIS: complete AIS; CAH: congenital adrenal hyperplasia; CHH: congenital hypogonadotropic hypogonadism; CXORF6: chromosome X open reading frame 6 gene; CYP19A1: cytochrome P450 family 19 subfamily A member 1 gene; DHT: dihydrotestosterone; DMRT1: double sex and mab-3 related transcription factor 1 gene; DSD: disorders of sexual development; GD: gonadal dysgenesis; HGMD: human gene mutation database; IH: isolated hypospadias; MAMLD1: mastermind like domain containing 1 gene; MIS: mullerian inhibiting substance; NTD: N-terminal domain; OT DSD: ovotesticular DSD; PAIS: partial AIS; SOX9: SRY-related HMG-box 9 gene; SRY: sex-determining region Y gene; STAR: steroidogenic acute regulatory protein gene; SRD5A2: steroid 5 alpha-reductase 2 gene; T DSD: testicular DSD; T: testosterone; WNT4: Wnt family member 4 gene; WT1: Wilms tumor 1 gene; Δ4: androstenedione.
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Affiliation(s)
- M R Nagaraja
- a Department of Biochemistry , Akash Institute of Medical Sciences & Research Centre , Bangalore , India
| | - Satya Prakash Gubbala
- b Division of Pharmacology and Toxicology , CSIR- Indian Institute of Chemical Technology , Hyderabad , India
| | - C R Wilma Delphine Silvia
- a Department of Biochemistry , Akash Institute of Medical Sciences & Research Centre , Bangalore , India
| | - Ramars Amanchy
- b Division of Pharmacology and Toxicology , CSIR- Indian Institute of Chemical Technology , Hyderabad , India
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Fisher AD, Ristori J, Morelli G, Maggi M. The molecular mechanisms of sexual orientation and gender identity. Mol Cell Endocrinol 2018; 467:3-13. [PMID: 28847741 DOI: 10.1016/j.mce.2017.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/02/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
Differences between males and females are widely represented in nature. There are gender differences in phenotypes, personality traits, behaviors and interests, cognitive performance, and proneness to specific diseases. The most marked difference in humans is represented by sexual orientation and core gender identity, the origins of which are still controversial and far from being understood. Debates continue on whether sexual behavior and gender identity are a result of biological (nature) or cultural (nurture) factors, with biology possibly playing a major role. The main goal of this review is to summarize the studies available to date on the biological factors involved in the development of both sexual orientation and gender identity. A systematic search of published evidence was performed using Medline (from January 1948 to June 2017). Review of the relevant literature was based on authors' expertise. Indeed, different studies have documented the possible role and interaction of neuroanatomic, hormonal and genetic factors. The sexual dimorphic brain is considered the anatomical substrate of psychosexual development, on which genes and gonadal hormones may have a shaping effect. In particular, growing evidence shows that prenatal and pubertal sex hormones permanently affect human behavior. In addition, heritability studies have demonstrated a role of genetic components. However, a convincing candidate gene has not been identified. Future studies (e.i. genome wide studies) are needed to better clarify the complex interaction between genes, anatomy and hormonal influences on psychosexual development.
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Affiliation(s)
- Alessandra D Fisher
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Jiska Ristori
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Girolamo Morelli
- Department of Surgical, Medical, Molecular and of the Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Mario Maggi
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy.
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Khorashad BS, Aghili Z, Kreukels BPC, Reid AG, Roshan GM, Hiradfar M, Talaei A, Cohen Kettenis PT. Mental Health and Disorders of Sex Development/Intersex Conditions in Iranian Culture: Congenital Adrenal Hyperplasia, 5-α Reductase Deficiency-Type 2, and Complete Androgen Insensitivity Syndrome. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:931-942. [PMID: 29294229 DOI: 10.1007/s10508-017-1139-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 09/12/2017] [Accepted: 12/14/2017] [Indexed: 06/07/2023]
Abstract
Sixty-one patients (22 patients with congenital adrenal hyperplasia [CAH] with a mean age of 14.86 years [range, 5-23], 20 patients with 5-α reductase deficiency type 2 [5α-RD-2] with a mean age of 19.5 years [range, 5-29], and 19 patients with complete androgen insensitivity syndrome [CAIS] with a mean age of 18.26 years [range, 5-28]) were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, the Structured Clinical Interview for DSM-IV Axis I, Axis II, and the Global Assessment Functioning Scale. All participants were female-assigned at birth. Ten patients (16.4%) transitioned to the male gender. Overall, 68% of patients had one or more lifetime Axis I disorders, including 63.6% of the CAH participants, 90% of 5α-RD-2 participants, and 52.6% of the CAIS participants. The most commonly observed were affective disorders (27.9%), gender identity disorder (27.9%), and anxiety (16.4%). Our study demonstrates that mental health of Iranian patients with DSD is at risk. This might be due to the fact that patients with DSD conditions are mostly treated medically and their mental health is often superficially addressed in developing countries such as Iran, at least in the past. We argue that it is important to pay attention to the mental health issues of patients with DSD and focus on specific issues, which may vary cross-culturally.
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Affiliation(s)
- Behzad S Khorashad
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran.
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran.
| | - Zahra Aghili
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Alistair G Reid
- Molecular Pathology Unit, Liverpool Clinical Laboratories, Liverpool, UK
| | - Ghasem M Roshan
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Mehran Hiradfar
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Peggy T Cohen Kettenis
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
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Kreukels BPC, Köhler B, Nordenström A, Roehle R, Thyen U, Bouvattier C, de Vries ALC, Cohen-Kettenis PT. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018; 15:777-785. [PMID: 29606626 DOI: 10.1016/j.jsxm.2018.02.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Information on the psychosexual outcome of individuals with disorders of sex development (DSDs) and intersex conditions is of great importance for sex assignment at birth of newborns with DSD. AIM To assess gender change and gender dysphoria in a large sample of individuals with different DSDs. METHODS A cross-sectional study was conducted in 14 European centers with 1,040 participants (717 female-identifying and 311 male-identifying persons and 12 persons identifying with another gender) with different forms of DSD. The cohort (mean age = 32.36 years, SD = 13.57) was divided into 6 major subgroups: women with 45,X DSD and variants (Turner syndrome; n = 325), men with 47,XXY DSD and variants (Klinefelter syndrome; n = 219), women with XY DSD without androgen effects (n = 107) and with androgen effects (n = 63), men with XY DSD (n = 87), and women with 46,XX congenital adrenal hyperplasia (n = 221). Data on psychosexual outcome were gathered by medical interviews and questionnaires. OUTCOMES Gender change and gender dysphoria. RESULTS Although gender changes were reported by 5% of participants, only in 1% (3% if those with Klinefelter and Turner syndromes-conditions in which gender issues are not prominent-are excluded) did the gender change take place after puberty and was likely initiated by the patient. 39 participants (4%) reported gender variance: between male and female, a gender other than male or female, or gender queer, alternating gender roles, or a gender expression that differed from the reported gender. This group had lower self-esteem and more anxiety and depression than the other participants. CLINICAL IMPLICATIONS Clinicians should be aware of and sensitive to the possibility that their patients with DSD not only might have transgender feelings and a desire to change gender, but also identify as different from male or female. The complexity of their feelings might require counseling for some patients. STRENGTHS AND LIMITATIONS The study is unique in the large number of participants from many different clinics, with sizable numbers in most subgroups, and in the large number of aspects that were measured. However, the very broadness of the study made it impossible to focus in detail on gender issues. Also, there is a need for instruments specifically measuring gender dysphoria in individuals with DSD that take non-binary genders into account. CONCLUSION To make appropriate gender care possible for people with DSD, the gender-normative and gender-variant development of children with DSD should be studied in longitudinal studies. Kreukels BPC, Köhler B, Nordenström A, et al. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018;15:777-785.
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Affiliation(s)
- Baudewijntje P C Kreukels
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - Birgit Köhler
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie CVK, Charité Universitätsmedizin, Berlin, Germany
| | - Anna Nordenström
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Robert Roehle
- Koordinierungszentrum Klinische Studien (KKS), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin Universität zu Lübeck, Lübeck, Germany
| | - Claire Bouvattier
- Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Paris Sud University, Paris, France
| | - Annelou L C de Vries
- Department of Child Psychiatry, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
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Bramble MS, Lipson A, Vashist N, Vilain E. Effects of chromosomal sex and hormonal influences on shaping sex differences in brain and behavior: Lessons from cases of disorders of sex development. J Neurosci Res 2017; 95:65-74. [PMID: 27841933 DOI: 10.1002/jnr.23832] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/30/2016] [Accepted: 06/20/2016] [Indexed: 01/15/2023]
Abstract
Sex differences in brain development and postnatal behavior are determined largely by genetic sex and in utero gonadal hormone secretions. In humans however, determining the weight that each of these factors contributes remains a challenge because social influences should also be considered. Cases of disorders of sex development (DSD) provide unique insight into how mutations in genes responsible for gonadal formation can perturb the subsequent developmental hormonal milieu and elicit changes in normal human brain maturation. Specific forms of DSDs such as complete androgen insensitivity syndrome (CAIS), congenital adrenal hyperplasia (CAH), and 5α-reductase deficiency syndrome have variable effects between males and females, and the developmental outcomes of such conditions are largely dependent on sex chromosome composition. Medical and psychological works focused on CAH, CAIS, and 5α-reductase deficiency have helped form the foundation for understanding the roles of genetic and hormonal factors necessary for guiding human brain development. Here we highlight how the three aforementioned DSDs contribute to brain and behavioral phenotypes that can uniquely affect 46,XY and 46,XX individuals in dramatically different fashions. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew S Bramble
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Allen Lipson
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Neerja Vashist
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Joseph AA, Kulshreshtha B, Shabir I, Marumudi E, George TS, Sagar R, Mehta M, Ammini AC. Gender Issues and Related Social Stigma Affecting Patients with a Disorder of Sex Development in India. ARCHIVES OF SEXUAL BEHAVIOR 2017; 46:361-367. [PMID: 27649694 DOI: 10.1007/s10508-016-0841-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 12/30/2015] [Accepted: 08/10/2016] [Indexed: 05/28/2023]
Abstract
Children with disorders of sex development (DSD) manifest at birth with malformed genitalia or later with atypical pubertal development. Those born with malformed genitalia are often diagnosed at birth. However, in resource-poor countries like India, where not all births are supervised by healthcare workers, some of these children remain undiagnosed until puberty or even later. The aim of this study was to assess the gender issues and psychosocial problems of children with DSD. Participants included 205 children with DSD (103 with 46,XX DSD and 102 with 46,XY DSD). Both the children with DSD and their parents underwent semistructured interviews by a clinical psychologist. The birth of a child with DSD was perceived as a major medical and social problem by parents from all socioeconomic strata. Mothers were distressed as many believed the DSD condition was transmitted through the mother. Children who were not diagnosed and treated during infancy or early childhood experienced considerable social discrimination not only from relatives and friends but also from medical and paramedical staff in hospitals. Several patients had been operated during infancy without an etiological diagnosis and without provision of adequate information to the parents. Some children had problems related to complications of surgery. Most teenage patients with 5α-reductase-2 deficiency reared as females presented with gender dysphoria, while children with androgen insensitivity (except for one) or with gonadal dysgenesis developed a gender identity concordant with their gender of rearing. Parents of children with DSD preferred a male gender assignment for their children (if that was possible) because of the social advantages of growing up male in a patriarchal society.
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Affiliation(s)
- Angela Ann Joseph
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Bindu Kulshreshtha
- Department of Endocrinology, Ram Manohar Lohia Hospital, New Delhi, India
| | - Iram Shabir
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Eunice Marumudi
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Tony Sam George
- Department of Psychology, Christ University, Bangalore, India
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Manju Mehta
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ariachery C Ammini
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
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11
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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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12
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Callens N, Van Kuyk M, van Kuppenveld JH, Drop SLS, Cohen-Kettenis PT, Dessens AB. Recalled and current gender role behavior, gender identity and sexual orientation in adults with Disorders/Differences of Sex Development. Horm Behav 2016; 86:8-20. [PMID: 27576114 DOI: 10.1016/j.yhbeh.2016.08.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 08/24/2016] [Accepted: 08/25/2016] [Indexed: 01/08/2023]
Abstract
The magnitude of sex differences in human brain and behavior and the respective contributions of biology versus socialization remain a topic of ongoing study in science. The preponderance of evidence attests to the notion that sexual differentiation processes are at least partially hormonally mediated, with high levels of prenatal androgens facilitating male-typed and inhibiting female-typed behaviors. In individuals with Disorders/Differences of Sex Development (DSD), hormonal profiles or sensitivities have been altered due to genetic influences, presumably affecting gender(ed) activity interests as well as gender identity development in a minority of the affected population. While continued postnatal androgen exposure in a number of DSD syndromes has been associated with higher rates of gender dysphoria and gender change, the role of a number of mediating and moderating factors, such as initial gender assignment, syndrome severity and clinical management remains largely unclear. Limited investigations of the associations between these identified influences and gendered development outcomes impede optimization of clinical care. Participants with DSD (n=123), recruited in the context of a Dutch multi-center follow-up audit, were divided in subgroups reflecting prenatal androgen exposure, genital appearance at birth and gender of rearing. Recalled childhood play and playmate preferences, gender identity and sexual orientation were measured with questionnaires and semi-structured interviews. Data were compared to those of control male (n=46) and female participants (n=79). The findings support that (a) prenatal androgen exposure has large effects on (gendered) activity interests, but to a much lesser extent on sexual orientation and that (b) initial gender of rearing remains a better predictor of gender identity contentedness than prenatal androgen exposure, beyond syndrome severity and medical treatment influences. Nonetheless, 3.3% of individuals with DSD in our sample self-reported gender dysphoria from an early age and changed gender, which further underlines the need for thorough long- term follow-up and specific clinical support.
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Affiliation(s)
- Nina Callens
- Department of Pediatrics, Division of Pediatric Endocrinology, University Hospital Ghent and Ghent University, Ghent, Belgium; Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maaike Van Kuyk
- Department of Medical Psychology, Radboud University Medical Center - Amalia Children's Hospital Nijmegen, The Netherlands
| | - Jet H van Kuppenveld
- Department of Medical Psychology, Radboud University Medical Center - Amalia Children's Hospital Nijmegen, The Netherlands
| | - Stenvert L S Drop
- Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, Vrije Universiteit Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Arianne B Dessens
- Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands.
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13
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Brunner F, Fliegner M, Krupp K, Rall K, Brucker S, Richter-Appelt H. Gender Role, Gender Identity and Sexual Orientation in CAIS ("XY-Women") Compared With Subfertile and Infertile 46,XX Women. JOURNAL OF SEX RESEARCH 2015; 53:109-124. [PMID: 26133743 DOI: 10.1080/00224499.2014.1002124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The perception of gender development of individuals with complete androgen insensitivity syndrome (CAIS) as unambiguously female has recently been challenged in both qualitative data and case reports of male gender identity. The aim of the mixed-method study presented was to examine the self-perception of CAIS individuals regarding different aspects of gender and to identify commonalities and differences in comparison with subfertile and infertile XX-chromosomal women with diagnoses of Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) and polycystic ovary syndrome (PCOS). The study sample comprised 11 participants with CAIS, 49 with MRKHS, and 55 with PCOS. Gender identity was assessed by means of a multidimensional instrument, which showed significant differences between the CAIS group and the XX-chromosomal women. Other-than-female gender roles and neither-female-nor-male sexes/genders were reported only by individuals with CAIS. The percentage with a not exclusively androphile sexual orientation was unexceptionally high in the CAIS group compared to the prevalence in "normative" women and the clinical groups. The findings support the assumption made by Meyer-Bahlburg ( 2010 ) that gender outcome in people with CAIS is more variable than generally stated. Parents and professionals should thus be open to courses of gender development other than typically female in individuals with CAIS.
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Affiliation(s)
- Franziska Brunner
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Maike Fliegner
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Kerstin Krupp
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Katharina Rall
- b Department of Obstetrics and Gynaecology , Tübingen University Hospital
| | - Sara Brucker
- b Department of Obstetrics and Gynaecology , Tübingen University Hospital
| | - Hertha Richter-Appelt
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
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14
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Berm�dez de la Vega JA, Fern�ndez-Cancio M, Bernal S, Aud� L. Complete Androgen Insensitivity Syndrome Associated with Male Gender Identity or Female Precocious Puberty in the Same Family. Sex Dev 2015; 9:75-9. [DOI: 10.1159/000371617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/19/2022] Open
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15
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Krupp K, Fliegner M, Brunner F, Brucker S, Rall K, Richter-Appelt H. Quality of Life and Psychological Distress in Women with Mayer-Rokitansky-Küster-Hauser Syndrome and Individuals with Complete Androgen Insensitivity Syndrome. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojmp.2014.33023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Roen K, Pasterski V. Psychological research and intersex/DSD: recent developments and future directions. PSYCHOLOGY & SEXUALITY 2013. [DOI: 10.1080/19419899.2013.831218] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
This article summarizes for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development (DSD) or with non-DSD transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA.
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18
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Ercan O, Kutlug S, Uysal O, Alikasifoglu M, Inceoglu D. Gender Identity and Gender Role in DSD Patients Raised as Females: A Preliminary Outcome Study. Front Endocrinol (Lausanne) 2013; 4:86. [PMID: 23874323 PMCID: PMC3711069 DOI: 10.3389/fendo.2013.00086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/29/2013] [Indexed: 12/31/2022] Open
Abstract
Gender identity and gender role are expected to be consistent with gender assignment for optimal DSD management outcome. To our knowledge, our study is the first to attempt evaluation of gender related outcomes in Turkish DSD patients. After receiving institutional ethical board approval and subject (or parent) informed consent, subjects with DSD raised as girls (22 patients 46 XX DSD, 11 patients 46 XY DSD) answered 566 questions of the Minnesota Multiphasic Personality Inventory (MMPI) questionnaire including 60-item Masculinity-Femininity (MF) subscale which was the focus in this study. Controls (n: 50) were females similar to the probands in age, level of education, relationship status, and having a job or not also answered all questions. The answers were evaluated by a trained psychologist (Derya Inceoglu) on MMPI. For statistical purposes, seven findings were obtained from the data related to the MF subscale from the patients and controls. Of these seven findings (S1-S7), two were associated with masculinity (S3-S4) and another two were associated with femininity (S5-S6). In DSD patients, the percentages of masculinity findings were significantly higher when compared to controls (p < 0.001 and p < 0.001 for S3 and S4, respectively). In controls, the percentages of femininity findings were significantly higher when compared to DSD females (p < 0.001 and p < 0.001 for S5 and S6 respectively). There was no significant difference between 46 XX DSD patients and 46 XY DSD patients with respect to the percentage of any of the seven findings. Two patients requested gender change to male; only these two patients had the finding stating that sexual impulses could come to existence as actions (S7). In conclusion efforts to identify modifiable factors with negative impact and thus modifying them, and professional guidance may be important in minimizing the encountered gender related problems in DSD patients.
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Affiliation(s)
- Oya Ercan
- Pediatric Endocrinology and Adolescent Divisions, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
- *Correspondence: Oya Ercan, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Fatih 34303, Istanbul, Turkey e-mail:
| | - Seyhan Kutlug
- Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Omer Uysal
- Department of Biostatistics and Medical Informatics, School of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Mujgan Alikasifoglu
- Adolescent Division, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Derya Inceoglu
- Academic Success Monitoring and Counseling Program, Center for Individual and Academic Development-CIAD, Sabanci University, Istanbul, Turkey
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Joseph AA, Shabir I, Marumadi E, Dada R, Ammini AC, Mehta M. Psychosexual outcomes in three siblings with partial androgen insensitivity syndrome: impact of nature versus nurture. J Pediatr Endocrinol Metab 2013; 26:915-20. [PMID: 23729553 DOI: 10.1515/jpem-2013-0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/22/2013] [Indexed: 11/15/2022]
Abstract
There are few reports of adults with disorders of sexual development (DSD). Here we describe the clinical profile and results of psychological assessment of three siblings with 46, XY DSD caused by partial androgen insensitivity syndrome (PAIS). The elder sibling (aged 22 years) was reared as female, while the middle and youngest siblings (17 and 18 years of age), were reared as males. The gender identity was concordant with the sex of rearing. There was no gender dysphoria. The psychological distress that our patients experienced was due to the limitations placed on them by their medical condition. It did not permit them to experience various facets of being either male or female completely. The younger siblings reared as males had additional problems of gynecomastia and lack of male secondary sexual development.
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20
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Jääskeläinen J. Molecular biology of androgen insensitivity. Mol Cell Endocrinol 2012; 352:4-12. [PMID: 21871529 DOI: 10.1016/j.mce.2011.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 07/19/2011] [Accepted: 08/10/2011] [Indexed: 12/29/2022]
Abstract
Androgen insensitivity syndrome (AIS) is the most common specific cause of 46,XY disorder in sex development. The androgen signaling pathway is complex but so far, the only gene linked with AIS is the androgen receptor (AR). Mutations in the AR are found in most subjects with complete AIS but in partial AIS, the rate has varied 28-73%, depending on the case selection. More than 400 different mutations in AR leading to AIS have been reported. Most mutations are missense substitutions located in the ligand binding domain of the receptor. However, when systematically screened, a substantial amount of mutations can be detected also in the N-terminal domain encoded by exon 1. Within this exon lie two trinucleotide, CAG and GGN repeat regions which are polymorphic in length. Their role in androgen insensitivity is somewhat unclear. Recent advances in protein modeling have resulted in better understanding of the mechanism of known AR mutations.
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Disorders of sex development: management of gender assignment in a preterm infant with intrauterine growth restriction. Case Rep Med 2012; 2012:587484. [PMID: 22489245 PMCID: PMC3318260 DOI: 10.1155/2012/587484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 12/01/2011] [Indexed: 11/18/2022] Open
Abstract
We describe how a gender specialist team managed the case of a disorder of sex development in a preterm infant where definitive diagnosis and gender assignment were delayed due to complications of prematurity, anemia, and severe intrauterine growth restriction.
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Cadet P. Androgen insensitivity syndrome with male sex-of-living. ARCHIVES OF SEXUAL BEHAVIOR 2011; 40:1101-1104. [PMID: 21809174 DOI: 10.1007/s10508-011-9823-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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T'Sjoen G, De Cuypere G, Monstrey S, Hoebeke P, Freedman FK, Appari M, Holterhus PM, Van Borsel J, Cools M. Male gender identity in complete androgen insensitivity syndrome. ARCHIVES OF SEXUAL BEHAVIOR 2011; 40:635-638. [PMID: 20358272 DOI: 10.1007/s10508-010-9624-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/06/2010] [Accepted: 03/17/2010] [Indexed: 05/29/2023]
Abstract
Women and girls with complete androgen insensitivity syndrome (CAIS) invariably have a female typical core gender identity. In this case report, we describe the first case of male gender identity in a CAIS individual raised female leading to complete sex reassignment involving both androgen treatment and phalloplasty. CAIS was diagnosed at age 17, based on an unambiguously female phenotype, a 46,XY karyotype, and a 2660delT androgen receptor (AR) gene mutation, leading to a premature stop in codon 807. Bilateral gonadectomy was performed but a short period of estrogen treatment induced a negative emotional reaction and treatment was stopped. Since the age of 3, childhood-onset cross gender behavior had been noticed. After a period of psychotherapy, persisting male gender identity was confirmed. There was no psychiatric co-morbidity and there was an excellent real life experience. Testosterone substitution was started, however without inducing any of the desired secondary male characteristics. A subcutaneous mastectomy was performed and the patient received phalloplasty by left forearm free flap and scrotoplasty. Testosterone treatment was continued, without inducing virilization, and bone density remained normal. The patient qualifies as female-to-male transsexual and was treated according to the Standards of Care by the World Professional Association for Transgender Health with good outcome. However, we do not believe that female sex of rearing as a standard procedure should be questioned in CAIS. Our case challenges the role of a functional AR pathway in the development of male gender identity.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology, Center for Sexology and Genderproblems, Ghent University Hospital, Belgium.
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Joseph AA, Kulshreshtha B, Mehta M, Ammini AC. Sex of rearing seems to exert a powerful influence on gender identity in the absence of strong hormonal influence: report of two siblings with PAIS assigned different sex of rearing. J Pediatr Endocrinol Metab 2011; 24:1071-5. [PMID: 22308869 DOI: 10.1515/jpem.2011.287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is an ongoing debate regarding the relative contribution of nurture over nature in development of gender identity. Patients with partial androgen insensitivity syndrome (PAIS) have ambiguous genitalia and are known to be reared as male or female. Familial cases of PAIS sharing common hormonal defects are usually reared in the same sex. Here, we describe two siblings with PAIS, one reared as a male and the other as female. These two siblings presented at adolescence. Gender identity was concordant with the sex of rearing for both. The male sibling was distressed with gynecomastia that had disrupted his social life. The sex of rearing seems to have played a predominant role in the formation of gender identity in these two patients with PAIS.
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Affiliation(s)
- Angela Ann Joseph
- Department of Psychiatry, All India Institute of Medical Sciences, Delhi, India
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Meyer-Bahlburg HFL. Gender outcome in 46,XY complete androgen insensitivity syndrome: comment on T'Sjoen et al. (2010). ARCHIVES OF SEXUAL BEHAVIOR 2010; 39:1221-1224. [PMID: 20552263 DOI: 10.1007/s10508-010-9640-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Meyer-Bahlburg HFL. Concerns regarding gender change to male in a 46,XY child with complete androgen insensitivity syndrome: comment on Kulshreshtha et al. (2009). ARCHIVES OF SEXUAL BEHAVIOR 2009; 38:876-877. [PMID: 19705270 DOI: 10.1007/s10508-009-9533-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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