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Calisti A, Salman DY, Belay K, Mombo A, Tresphory B, Giuliani G, Sertori M, Parigi GB. The hidden burden of Pediatric urology in Sub-Saharan Africa: an analysis of hospital admission data from three East African Health Centres. LA PEDIATRIA MEDICA E CHIRURGICA 2024; 46. [PMID: 38270180 DOI: 10.4081/pmc.2024.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024] Open
Abstract
Specialist facilities for children are still unavailable in some Sub-Saharan African contexts. It is the case of pediatric urology, whose recent advances are still largely unshared. Prenatal diagnosis of urinary abnormalities (CAKUT) is largely unknown. Early recognition and referral of Undescended testis (UDT), Hypospadia, bladder exstrophy epispadias complex, ambiguous genitalia, stone disease, and tumours are uncommon in rural areas. Missed diagnosis is not uncommon and delayed management is associated with poor outcomes. We present a cross-sectional, descriptive study about the epidemiology of Pediatric urological admissions to three sub-Saharan East African Hospitals. All the urological cases between 0-18 years referred to three distinct East African Hospitals over 124 weeks were considered. Prevalence of different groups of diseases, age, and mode of presentation were reported. We found 351 cases (M/F 127/24) out of 2543 surgical referrals (13%). Seventy percent of cases were Hypospadias and UDT. Fifty percent of UDT were beyond 6, and most Hypospadias were between 4 and 7 yrs. CAKUT had a very low prevalence (4.84%), and about 50% of Wilms Tumours came too late to be resectable. In many African contexts, urology is still a tiny portion of the pediatric surgical workload compared to the 25% of European and American reports. There are also differences in the epidemiology of genitourinary conditions. A hidden burden of diseases may be presumed, remaining undiagnosed due to the shortage of specialist facilities.
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Affiliation(s)
| | | | - Kibreab Belay
- Department of Surgery, Orotta National Referral Hospital, Asmara.
| | - Andrea Mombo
- Department of Urology, Consolata Hospital Ikonda, Makete.
| | | | | | | | - Gian Battista Parigi
- Department of Pediatric Surgery, University of Pavia, IRCCS Policlinico S. Matteo, Pavia.
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Mohamed MS, Halim ZA, Azizan SA. Management of Gender Determination of Newborns and Children with Disorders of Sex Development Using a Multidisciplinary Approach: An Exploratory Study of Islamic Perspective in Malaysia. JOURNAL OF RELIGION AND HEALTH 2023; 62:797-818. [PMID: 36070127 DOI: 10.1007/s10943-022-01657-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
Management of newborns with disorders of sex development (DSD), especially in deciding the need for a sex assignment surgery, is a complex matter. It is associated with many bioethical issues, such as concerns about the rights and welfare of the newborns and the reliability of parents' consent to the paternalistic disposition of physicians in making the best decisions. This paper, containing interviews with six medical experts and three religious' experts, aims to raise awareness of the multidisciplinary approach, which uses a combination of medicine, religion, and ethics in managing children with DSD, particularly in Malaysia, to avoid unnecessary psychological, biological, emotional, and societal ramifications.
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Affiliation(s)
- Mohd Salim Mohamed
- Department of Science and Technology Studies, Faculty of Science, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Zulaikha Abdul Halim
- Department of Science and Technology Studies, Faculty of Science, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Suzana Ariff Azizan
- Department of Science and Technology Studies, Faculty of Science, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
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3
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Bucher ML, Anderson FL, Lai Y, Dicent J, Miller GW, Zota AR. Exposomics as a tool to investigate differences in health and disease by sex and gender. EXPOSOME 2023; 3:osad003. [PMID: 37122372 PMCID: PMC10125831 DOI: 10.1093/exposome/osad003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 05/02/2023]
Abstract
The health and disease of an individual is mediated by their genetics, a lifetime of environmental exposures, and interactions between the two. Genetic or biological sex, including chromosome composition and hormone expression, may influence both the types and frequency of environmental exposures an individual experiences, as well as the biological responses an individual has to those exposures. Gender identity, which can be associated with social behaviors such as expressions of self, may also mediate the types and frequency of exposures an individual experiences. Recent advances in exposome-level analysis have progressed our understanding of how environmental factors affect health outcomes; however, the relationship between environmental exposures and sex- and gender-specific health remains underexplored. The comprehensive, non-targeted, and unbiased nature of exposomic research provides a unique opportunity to systematically evaluate how environmental exposures interact with biological sex and gender identity to influence health. In this forward-looking narrative review, we provide examples of how biological sex and gender identity influence environmental exposures, discuss how environmental factors may interact with biological processes, and highlight how an intersectional approach to exposomics can provide critical insights for sex- and gender-specific health sciences.
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Affiliation(s)
| | - Faith L Anderson
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, New York, NY, USA
| | - Yunjia Lai
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, New York, NY, USA
| | - Jocelyn Dicent
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, New York, NY, USA
| | - Gary W Miller
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, New York, NY, USA
| | - Ami R Zota
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, New York, NY, USA
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4
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Waehre A, Heggeli C, Hald K, Myhre AG, Diseth T. A 15–20-year follow-up of mental health, psychosocial functioning and quality of life in a single center sample of individuals with differences in sex development. Health Psychol Behav Med 2022; 10:837-854. [PMID: 36105256 PMCID: PMC9467622 DOI: 10.1080/21642850.2022.2116329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: The aim of the study was to present metal health, psychosocial functioning and quality of life (QoL) of children and adolescents with a difference in sex development (DSD) from their first visit in the newly established multidisciplinary team in 2002–2004 in Norway. A secondary aim was to explore mental health, psychosocial functioning and QoL in the same cohort patient’s as for today and finally explore any childhood predictors for these outcomes in adulthood. Methods: The first part of the study took place in 2002–2004 in a mixed cohort of children and adolescents born with a DSD in 1982–2002, compared to a healthy comparison group. This part involved semi-structured interviews and self-reported and proxy-reported questionnaires. The second part of the study is a longitudinal study of the same participants 15–20 years later (2018–2020). Results: The participants at baseline of the study consisted of 33 patients; 24 assigned females (congenital adrenal hyperplasia, androgen insensitivity syndrome, gonadal dysgenesis and ovotesticular DSD) and nine assigned males; all with a hypospadias diagnosis. Significant differences were found for behavioral and emotional problems between groups, 46, XX females with significant higher total scores on YSR (49.43 + 24.17, p = .047); 46, XY females (21.00 + 12.04, p = .032); and higher internalizing problems scores (YSR) in 46, XX females (16.57 + 9.74), compared with the 46, XY females (5.60 + 5.32, p = .047). A positive association between QoL of the participants in adulthood and PedsQL’ social function (r = .657, p = .020) and psychosocial function in childhood (r = .596, p = .041) was found. Conclusions: In summary, this study demonstrated that adolescents assigned females with DSD might have more psychiatric problems and a poorer degree of psychosocial functioning compared to a healthy comparison group. As we do find an association with these problems in adolescence and later adult QoL, it is of great importance to respond to these behaviors in early life.
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Affiliation(s)
- Anne Waehre
- Division of Paediatric and Adolescent Medicine, Department of Child and Adolescent Mental Health in Hospital, Oslo University Hospital, Oslo, Norway
| | | | - Kirsten Hald
- Division of Gynaecology and Obstetrics, Department of Gynaecology, Oslo University Hospital, Oslo, Norway
| | | | - Trond Diseth
- Division of Paediatric and Adolescent Medicine, Department of Child and Adolescent Mental Health in Hospital, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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5
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Traitement chirurgical des malformations génitales de l’enfant- contexte juridique. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Nordenström A, Ahmed SF, van den Akker E, Blair J, Bonomi M, Brachet C, Broersen LHA, Claahsen-van der Grinten HL, Dessens AB, Gawlik A, Gravholt CH, Juul A, Krausz C, Raivio T, Smyth A, Touraine P, Vitali D, Dekkers OM. Pubertal induction and transition to adult sex hormone replacement in patients with congenital pituitary or gonadal reproductive hormone deficiency: an Endo-ERN clinical practice guideline. Eur J Endocrinol 2022; 186:G9-G49. [PMID: 35353710 PMCID: PMC9066594 DOI: 10.1530/eje-22-0073] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
An Endo-European Reference Network guideline initiative was launched including 16 clinicians experienced in endocrinology, pediatric and adult and 2 patient representatives. The guideline was endorsed by the European Society for Pediatric Endocrinology, the European Society for Endocrinology and the European Academy of Andrology. The aim was to create practice guidelines for clinical assessment and puberty induction in individuals with congenital pituitary or gonadal hormone deficiency. A systematic literature search was conducted, and the evidence was graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. If the evidence was insufficient or lacking, then the conclusions were based on expert opinion. The guideline includes recommendations for puberty induction with oestrogen or testosterone. Publications on the induction of puberty with follicle-stimulation hormone and human chorionic gonadotrophin in hypogonadotropic hypogonadism are reviewed. Specific issues in individuals with Klinefelter syndrome or androgen insensitivity syndrome are considered. The expert panel recommends that pubertal induction or sex hormone replacement to sustain puberty should be cared for by a multidisciplinary team. Children with a known condition should be followed from the age of 8 years for girls and 9 years for boys. Puberty induction should be individualised but considered at 11 years in girls and 12 years in boys. Psychological aspects of puberty and fertility issues are especially important to address in individuals with sex development disorders or congenital pituitary deficiencies. The transition of these young adults highlights the importance of a multidisciplinary approach, to discuss both medical issues and social and psychological issues that arise in the context of these chronic conditions.
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Affiliation(s)
- A Nordenström
- Pediatric Endocrinology, Department of Women’s and Children’s Health Karolinska Institutet, and Department of Pediatric Endocrinology and Inborn Errors of Metabolism, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Correspondence should be addressed to A Nordenström;
| | - S F Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Royal Hospital for Children, Glasgow, UK
| | - E van den Akker
- Division of Pediatric Endocrinology and Obesity Center CGG, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J Blair
- Department of Endocrinology, Alder Hey Children’s Hospital, Liverpool, UK
| | - M Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - C Brachet
- Pediatric Endocrinology Unit, Hôpital Universitaire des Enfants HUDERF, Université Libre de Bruxelles, Bruxelles, Belgium
| | - L H A Broersen
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - H L Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Childrens Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A B Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Sophia Children’s Hospital Erasmus Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium
| | - A Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - C H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - A Juul
- Department of Growth and Reproduction, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- International Research and Research Training Centre for Endocrine Disruption in Male Reproduction and Child Health (EDMaRC) and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C Krausz
- Department of Biochemical, Experimental and Clinical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
| | - T Raivio
- New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, and Research Program Unit, Faculty of Medicine, Stem Cells and Metabolism Research Program, University of Helsinki, Helsinki, Finland
| | - A Smyth
- Turner Syndrome Support Society in the UK, ePAG ENDO-ERN, UK
| | - P Touraine
- Department of Endocrinology and Reproductive Medicine, Pitié Salpêtriere Hospital, Paris, France
- Sorbonne Université Médecine and Center for Endocrine Rare Disorders of Growth and Development and Center for Rare Gynecological Disorders, Paris, France
| | - D Vitali
- SOD ITALIA APS – Italian Patient Organization for Septo Optic Dysplasia and Other Neuroendocrine Disorders – ePAG ENDO-ERN, Rome, Italy
| | - O M Dekkers
- Department of Clinical Epidemiology, LUMC Leiden, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Sandberg DE, Gardner M. Differences/Disorders of Sex Development: Medical Conditions at the Intersection of Sex and Gender. Annu Rev Clin Psychol 2022; 18:201-231. [PMID: 35216524 PMCID: PMC10170864 DOI: 10.1146/annurev-clinpsy-081219-101412] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Defined as congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical, differences or disorders of sex development (DSDs) comprise many discrete diagnoses ranging from those associated with few phenotypic differences between affected and unaffected individuals to those where questions arise regarding gender of rearing, gonadal tumor risk, genital surgery, and fertility. Controversies exist in numerous areas including how DSDs are conceptualized, how to refer to the set of conditions and those affected by them, and aspects of clinical management that extend from social media to legislative bodies, courts of law, medicine, clinical practice, and scholarly research in psychology and sociology. In addition to these aspects, this review covers biological and social influences on psychosocial development and adjustment, the psychosocial and psychosexual adaptation of people born with DSDs, and roles for clinical psychologists in the clinical management of DSDs. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
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Ekenze SO, Chikani U, Ezomike UO, Adiri CO, Onuh A. Clinical profile and management challenges of disorders of sex development in Africa: a systematic review. J Pediatr Endocrinol Metab 2022; 35:139-146. [PMID: 34670035 DOI: 10.1515/jpem-2021-0510] [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: 08/01/2021] [Accepted: 10/04/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To review the published literature regarding disorders of sex development (DSD) in Africa which will highlight clinical characteristics, and challenges of evaluation and treatment of DSD. CONTENT We performed systematic review of articles published on DSD in Africa between January 2001 and December 2020. SUMMARY Eighteen studies involving 1980 patients from nine countries were analyzed. Overall mean age at presentation was 9.3 years (range 1 day-33 years) with 52.5 and 45.1% reared as females and males, respectively, prior to presentation. Following evaluation however, 64% were assigned female sex, 32.1% were assigned male sex, and 21.8% of the cases required sex reassignment. Only 7 (38.9%) of the publications reported medical treatment of DSD, 4 (22.2%) reported on psychosocial management and 5 (27.8%) documented multidisciplinary team management. Barring regional variations, the documented challenges of management include delayed presentation, loss to follow up, financial challenges, and lack of facilities for care of DSD. Comparison of the cases managed in the last decade (2011-2020) with those managed in the earlier decade (2001-2010) showed a trend towards earlier presentation and reduced rate of sex reassignment in the last decade. However, the challenges persisted. OUTLOOK Barring regional differences, a high proportion of DSD in Africa may have delayed presentation with inappropriate sex of rearing, inadequate evaluation and need for sex reassignment. Specific efforts to improve time to diagnosis, patient evaluation, improvement of healthcare funding, and collaboration with more developed countries may improve the care of patients with DSD in Africa.
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Affiliation(s)
- Sebastian O Ekenze
- Sub-Department of Paediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ugo Chikani
- Department of Paediatrics, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Uchechukwu O Ezomike
- Sub-Department of Paediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Charles O Adiri
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Augustine Onuh
- Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
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9
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Utari A, Faradz SMH, Ediati A, Rinne T, Ariani MD, Juniarto AZ, Drop SLS, van Herwaarden AE, Claahsen-van der Grinten HL. Challenges in the treatment of late-identified untreated congenital adrenal hyperplasia due to CYP11B1 deficiency: Lessons from a developing country. Front Endocrinol (Lausanne) 2022; 13:1015973. [PMID: 36589846 PMCID: PMC9797803 DOI: 10.3389/fendo.2022.1015973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Congenital Adrenal Hyperplasia (CAH) due to CYP11B1 is a rare autosomal recessive adrenal disorder that causes a decrease in cortisol production and accumulation of adrenal androgens and steroid precursors with mineralocorticoid activity. Clinical manifestations include cortisol deficiency, ambiguous genitalia in females (differences of sex development (DSD)), and hypertension. Medical treatment recommendations are well defined, consisting of glucocorticoid treatment to substitute glucocorticoid deficiency and consequently normalize adrenal androgen and precursors levels. Current guidelines also emphasize the need for specialized multidisciplinary DSD teams and psychosocial support. In many developing countries, care for DSD patients, especially when caused by an adrenal disease, is challenging due to the lack of infrastructure, knowledge, and medication. OBJECTIVE The study aims to report the conflicting decision-making process of medical treatment and sex assignment in late-identified CAH patients in developing countries. METHODS We describe the clinical and biochemical findings and the psychological assessment of five affected but untreated family members with CAH due to CYP11B1 deficiency. RESULTS All patients had a 46,XX karyotype, ambiguous genitalia, low cortisol levels, and hypertension. Two identified as males, two as females, and one had undecided gender. The patients were counselled that refusing treatment will lead to infertility and the potential risk of developing Addisonian crisis and severe hypertension. However, all 46,XX CAH males refused treatment with glucocorticoids due to the expected lowering of adrenal androgens as their main source of testosterone. None of the patients developed Addisonian crisis, probably due to some residual cortisol activity and glucocorticoid activity of elevated adrenal steroid precursors. CONCLUSION Medical treatment and sex assignment in late-identified 46,XX CAH patients in Indonesia may often depend on local and cultural factors. The management of DSD conditions may have to be individualized and integrated into the psychological and social context of the affected family.
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Affiliation(s)
- Agustini Utari
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- *Correspondence: Agustini Utari,
| | - Sultana M. H. Faradz
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Annastasia Ediati
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Faculty of Psychology, Diponegoro University, Semarang, Indonesia
| | - Tuula Rinne
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mahayu Dewi Ariani
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Achmad Zulfa Juniarto
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stenvert L. S. Drop
- Division of Pediatric Endocrinology, Sophia Children’s Hospital and Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Hedi L. Claahsen-van der Grinten
- Division of Pediatric Endocrinology, Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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11
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Listyasari NA, Juniarto AZ, Robevska G, Ayers KL, Sinclair AH, Faradz SMH. Analysis of the androgen receptor (AR) gene in a cohort of Indonesian undermasculinized 46, XY DSD patients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2021. [DOI: 10.1186/s43042-021-00134-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
Background
Pathogenic variants in the androgen receptor (AR) gene located on chromosome Xq11-12, are known to cause varying degrees of undermasculinization in 46, XY individuals. The aim of this study was to investigate the frequency of pathogenic variants in the AR gene in a cohort of 46, XY undermasculinized individuals from Indonesia who were suspected of having androgen insensitivity syndrome (AIS). All patients with 46, XY DSD referred to our center between 1994 and 2019 were collected from our clinical database. All 46, XY DSD patients without a prior molecular diagnosis with an external masculinization score (EMS) ≤ 9 were included in this study. All exons and intron–exon boundaries of AR gene were analyzed using Sanger sequencing to identify pathogenic variants of the AR gene.
Results
A cohort of 75 undermasculinized patients were selected for the study. Direct Sanger sequencing of all eight exons of the AR gene led to a genetic diagnosis in 11 patients (14.67%). All of the variants identified (p.Arg841His; p.Ile604Asn; p.Val731Met; p.Pro672Ser; p.Gln739Arg; p.Ser302Glufs*3) have been previously reported in patients with AIS.
Conclusions
This is the first study in Indonesia that highlights the significance of molecular analysis in providing a definitive diagnosis of AIS for patients with 46, XY DSD undermasculinization. This is an uncommon finding in the Indonesian population presenting with 46, XY DSD undermasculinization. A genetic diagnosis allows optimal clinical management and genetic counseling for patients and their families. As 46, XY DSD can be caused by pathogenic variants in other genes involved in gonadal development and differentiation, further genetic analysis, such as whole exome sequencing, should be carried out on those patients that did not carry an AR variant.
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12
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Bertelloni S, Tyutyusheva N, Valiani M, D'Alberton F, Baldinotti F, Caligo MA, Baroncelli GI, Peroni DG. Disorders/Differences of Sex Development Presenting in the Newborn With 46,XY Karyotype. Front Pediatr 2021; 9:627281. [PMID: 33968844 PMCID: PMC8100517 DOI: 10.3389/fped.2021.627281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions, resulting in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. The management of a newborn with suspected 46,XY DSD remains challenging. Newborns with 46,XY DSD may present with several phenotypes ranging from babies with atypical genitalia or girls with inguinal herniae to boys with micropenis and cryptorchidism. A mismatch between prenatal karyotype and female phenotype is an increasing reason for presentation. Gender assignment should be avoided prior to expert evaluation and possibly until molecular diagnosis. The classic diagnostic approach is time and cost-consuming. Today, a different approach may be considered. The first line of investigations must exclude rare life-threatening diseases related to salt wasting crises. Then, the new genetic tests should be performed, yielding increased diagnostic performance. Focused imaging or endocrine studies should be performed on the basis of genetic results in order to reduce repeated and invasive investigations for a small baby. The challenge for health professionals will lie in integrating specific genetic information with better defined clinical and endocrine phenotypes and in terms of long-term evolution. Such advances will permit optimization of counseling of parents and sex assignment. In this regard, society has significantly changed its attitude to the acceptance and expansion beyond strict binary male and female sexes, at least in some countries or cultures. These management advances should result in better personalized care and better long-term quality of life of babies born with 46,XY DSD.
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Affiliation(s)
- Silvano Bertelloni
- Paediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nina Tyutyusheva
- Paediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Margherita Valiani
- Paediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Fulvia Baldinotti
- Laboratory of Molecular Genetics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Adelaide Caligo
- Laboratory of Molecular Genetics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giampiero I Baroncelli
- Paediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego G Peroni
- Paediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Khan S, Tafweez R, Haider A, Yaqoob M. Spectrum of external genital anomalies in disorders of Sex Development at Children Hospital & Institute of Child Health, Lahore, Pakistan. Pak J Med Sci 2020; 37:244-249. [PMID: 33437285 PMCID: PMC7794156 DOI: 10.12669/pjms.37.1.2991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe the mode of presentation and frequency of external genital anomalies in disorder of sex development (DSD) Methods: This cross-sectional study was conducted at Children Hospital & Institute of Child Health, Lahore from January to December, 2016 on Children with DSD above 10 years of age. A detailed history and physical examination were done. Positive findings were recorded on a predesigned proforma and analyzed by SPSS 21. Karyotyping on blood samples was done to determine their genetic sex. Results: Out of 83 DSD children, 67% (n=56) were assigned a female sex at birth of which 9% (n=5) had ambiguous genitalia. Male sex at birth was given to 33% (n=27) of which 96% (n=26) had genital ambiguity. Mode of presentation other than ambiguous genitalia were delayed puberty, amenorrhea, hirsuitism, gynaecomastia, cyclic hematuria etc. Clitoromegaly was the main finding in 62.5% (n=5) and micropenis in 45% (n=9). Karyotypic sex of 56 female sex of rearing was 46XX 80% (n=45), 45X0 13% (n=7), XXX 2% (n=1) and 46 XY in 5% (n=3). Karyotypic sex of 27 male sex of rearing was 46XY in 78% (n=21), 46XX in 15% (n=4) and 47XXY in 7% (n=2). Conclusion: Disorders of sex development presented with a wide spectrum of external genital anomalies ranging from clitoromegaly in females to micropenis and hypospadias in males. There was also an extreme diversity in mode of presentation of these cases including pubertal delay, amenorrhea in females and gender confusion disorders.
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Affiliation(s)
- Sarah Khan
- Dr. Sarah Khan, MBBS, M-Phil Anatomy Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Raafea Tafweez
- Dr. Raafea Tafweez, MBBS, M-Phil, FCPS, PhD. Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Areiba Haider
- Dr. Areiba Haider, MBBS, M-Phil. Anatomy, Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Yaqoob
- Dr. Muhammad Yaqoob, MBBS, MCPS, PhD. Associate Professor of Genetics, Department of Genetics, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
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Xu K, Su N, Zhang H, Zhu J, Cheng X. A case report of 46,XY partial gonadal dysgenesis caused by a novel mutation in the sex-determining region gene. Transl Pediatr 2020; 9:867-872. [PMID: 33457310 PMCID: PMC7804473 DOI: 10.21037/tp-20-414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The sex-determining region Y (SRY) gene is a key gene involved in male sex differentiation and development. Patients with 46,XY disorders of sex development related to mutations in the high mobility group (HMG) box typically present with complete gonadal dysgenesis. In this study, we report a case of novel missense mutation c.T281G within the HMG domain of SRY in a 15-year-old patient of the female gender with 46,XY partial gonadal dysgenesis (PGD). The novel missense mutation caused the substitution of codon 94 for leucine in the HMG box of the SRY protein with an arginine codon. Leucine and arginine are aliphatic amino acids, and three-dimensional protein structure prediction revealed only slight structural changes in the SRY protein. Thus, the SRY protein had maintained some of its functions, and the patient presented with PGD. In conclusion, we identified a novel SRY mutation in a patient with 46,XY PGD. Based on the protein model, we believe that the mutation in the HMG domain helped to maintain the partial function of the SRY protein. The condition of our patient differed from the well-known 46,XY complete gonadal dysgenesis caused by mutations in the HMG region. In fact, this is the first case of 46,XY PGD caused by mutations in the HMG region to be reported, and therefore, our experience has expanded the mutation spectrum of the SRY gene. Furthermore, the present case demonstrates that mutations located in the HMG domain of SRY gene cannot be ruled out in patients with a clinical diagnosis of 46,XY PGD.
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Affiliation(s)
- Ke Xu
- Department of Genetics and Endocrinology, Chengdu Women's and Children's Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Na Su
- Department of Genetics and Endocrinology, Chengdu Women's and Children's Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hong Zhang
- Department of Genetics and Endocrinology, Chengdu Women's and Children's Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jingxin Zhu
- Department of Genetics and Endocrinology, Chengdu Women's and Children's Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xinran Cheng
- Department of Genetics and Endocrinology, Chengdu Women's and Children's Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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15
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Krege S. Reformen in der Behandlung von Menschen mit Varianten der Geschlechtsdifferenzierung. Urologe A 2020; 59:1356-1360. [DOI: 10.1007/s00120-020-01329-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Behrens KG. A principled ethical approach to intersex paediatric surgeries. BMC Med Ethics 2020; 21:108. [PMID: 33121480 PMCID: PMC7597036 DOI: 10.1186/s12910-020-00550-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery for intersex infants should be delayed until individuals are able to decide for themselves, except where it is a medical necessity. In an ideal world, this single principle would suffice and such surgeries could be totally prohibited. Unfortunately, the world is not perfect, and, in some places, intersex neonates are at risk of being abandoned, mutilated or even killed. As long as intersex persons are at such high risk in some places, any ethical guidelines for intersex surgeries will need to take these extreme risks of harm into account. MAIN TEXT I therefore argue for five basic principles that ought to inform ethics guidelines for surgical interventions in intersex children, specifically in contexts in which such children are at risk of significant harm. What I set out to come up with is a set of principles that do not completely prohibit surgery, but only allow it where a strong case can be made for its necessity, in the best interests of the child, and where there is some kind of oversight to prevent misuse. The first principle is that interventions as drastic as these surgeries should only be performed when there is strong evidence that they are beneficial and not harmful. The second principle is that in surgeries should normally only be performed in cases of true medical necessity. Principle three is that surgeries should normally be delayed until such time as the intersex person is mature enough to assent to treatment or decide against it. Principle four is that the conventional ethical requirements regarding truth telling apply equally to intersex children as to anyone else. The final principle is that where physicians or parents think that surgery is in the best interests of the child, the burden of proof lies with them. CONCLUSION It is hoped that these principles might help medical teams and parents make better decisions about intersex surgeries on children, and they would make such surgeries very rare indeed, if they happen at all.
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Affiliation(s)
- Kevin G Behrens
- Steve Biko Centre for Bioethics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Phillip V. Tobias Health Sciences Building, 29 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
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Ernst MM, Kogan BA, Lee PA. Gender identity: A psychosocial primer for providing care to patients with a disorder/difference of sex development and their families [individualized care for patients with intersex (Disorders/differences of sex development): Part 2]. J Pediatr Urol 2020; 16:606-611. [PMID: 32819812 PMCID: PMC7890938 DOI: 10.1016/j.jpurol.2020.06.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION/BACKGROUND Many parents of infants born with a DSD describe the process of initial sex assignment at birth as highly stressful. Parents of children with a DSD also note high distress when their children engage in behaviors that are not considered typical for their gender. OBJECTIVE The goal of this article is to provide members of the health care team a brief overview of psychosocial facets of gender and gender identity particularly relevant to DSD for the purposes of enhancing shared decision-making and optimizing support for individuals with a DSD and their families. DISCUSSION Gender identity is a multidimensional construct involving related but distinct concepts such as gender typicality, gender contentedness and felt pressure for gender differentiation, and can be assessed via standardized measures. Gender dysphoria is associated with poor psychological adjustment, and is mitigated by family and peer support. Family influences on gender identity include parental modeling of gender behavior and family composition (e.g., same-sex children vs both sons and daughters in a family). Cultural factors that may influence sex assignment include societal views on gender, and gender-related differential resource allocation within a society. In addition, religious beliefs and the presence of a "third-sex" category within a culture may also influence parental gender ideology. CLINICAL APPLICATION Health care providers who work with patients with a DSD must have a strong grasp on the construct of gender identity, and must be able to clearly and consistently communicate with patients and families about gender beliefs in order to optimize family support and gender-related decisions.
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Affiliation(s)
- Michelle M Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA; Differences of Sex Development Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.
| | | | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA.
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18
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Zeeman L, Aranda K. A Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186533. [PMID: 32911732 PMCID: PMC7559554 DOI: 10.3390/ijerph17186533] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 01/22/2023]
Abstract
Extensive research documents the health inequalities LGBTI people experience, however far less is known for people with intersex variation. This paper presents a review of intersex health and healthcare inequalities by evaluating research published from 2012 to 2019. In total 9181 citations were identified with 74 records screened of which 16 were included. A synthesis of results spans nine quantitative, five qualitative and two narrative reviews. Literature was searched in Medline, Web of Science, Cochrane, PsycInfo and CINAHL. People with intersex variance experience a higher incidence of anxiety, depression and psychological distress compared to the general population linked to stigma and discrimination. Progressive healthcare treatment, including support to question normative binaries of sex and gender, aids understand of somatic intersex variance and non-binary gender identity, especially when invasive treatment options are avoided or delayed until individuals are able to self-identify or provide consent to treatment. Findings support rethinking sex and gender to reflect greater diversity within a more nuanced sex-gender spectrum, although gaps in research remain around the general health profile and the healthcare experiences of people with intersex variance. More large-scale research is needed, co-produced with peers who have lived experience of intersex variation to ensure policy, education and healthcare advances with greater inclusivity and ethical accountability.
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Affiliation(s)
- Laetitia Zeeman
- School of Health Sciences, University of Brighton, Brighton BN1 9PH, UK;
- Centre for Transforming Sexuality and Gender, University of Brighton, Brighton BN2 0JG, UK
- Correspondence: ; Tel.: +44-0-1273-64-4194
| | - Kay Aranda
- School of Health Sciences, University of Brighton, Brighton BN1 9PH, UK;
- Centre for Transforming Sexuality and Gender, University of Brighton, Brighton BN2 0JG, UK
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19
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Abstract
Differences of sex development (DSD) include a variety of complex congenital genitourinary abnormalities-whether sporadic or hereditary. The 2006 DSD Consensus Statement and 2016 Update Consensus Statement encourage better communication among providers, between providers and parents, as well as among providers, parents, and patients when developmentally appropriate.1,2 However, a lack of clear communication about the diagnosis and its sequelae may occur at three levels: (1) disclosure from DSD patients' families to their physician, (2) disclosure from patients to their families/communities, and (3) disclosure from the physician to the DSD patient. Additionally, there is a paucity of research available on how culture can impact disclosure among individuals with DSDs. This article discusses disclosure among the various stakeholders and briefly explores the impact of cultural expectations and beliefs with regards to disclosure.
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Affiliation(s)
- Erica M Weidler
- Reproductive Anomalies/Differences of Sex Development Clinic, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States.
| | - Karen E Peterson
- Reproductive Anomalies/Differences of Sex Development Clinic, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States
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20
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Ekenze SO, Chikani UN, Ezomike UO, Okafor DC. Outcome of feminizing genital reconstruction in female sex assigned disorder of sex development in a low-income country. J Pediatr Urol 2019; 15:244-250. [PMID: 30926253 DOI: 10.1016/j.jpurol.2019.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist. OBJECTIVE This study evaluates the outcome of genital surgery in patients with DSD assigned female sex. METHODS A retrospective analysis of 25 cases of female sex assigned DSD managed in two tertiary centers in southeast Nigeria was performed. Data of these cases were collected from the case notes, discharge summaries, and theater records. IBM SPSS Statistics Data Editor, version 21, was used for data entry and analysis. RESULTS The patients presented at median age of 12 months (range 2 days-30 years), with 15 (60%) cases reared as female and 10 (40%) reared as male before presentation. The predominant phenotype was phallus with empty fused/unfused labioscrotum and urethra opening in the labioscrotum or perineum in 21 (84%) patients. Evaluation revealed features suggestive of 46XX DSD in 21 (84%) patients, ovotesticular DSD in two (8%), and androgen insensitivity in two (8%). A total of 10 cases required sex reassignment after evaluation. Overall, 24 of the 25 cases had feminizing genital procedures. After a median follow-up period of 2 years (range 2 months-8 years), six (25%) cases developed procedure-related complications, three (12.5%) had social maladjustment, and two (8.3%) patients reported features of gender dysphoria. DISCUSSION The procedures of feminizing genitoplasty in this study did not differ from the established procedure. However, as a result of challenges of delayed presentation, inadequate early management, sociocultural factors, and a lack of facilities for full evaluation, some cases may require sex reassignment and more daunting reconstructive procedures. This may give rise to less than optimal outcome. The study was limited by the retrospective nature, small number of cases, and the short duration of follow-up of the cases. CONCLUSION Feminizing genital procedures for DSD in our setting may be associated with procedure-related complications and non-surgical complications. Improving surgical technique and addressing the challenges of delayed presentation and fixation on male gender may improve overall outcome.
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Affiliation(s)
- S O Ekenze
- Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Enugu Campus, Nigeria.
| | - U N Chikani
- Endocrine Unit, Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - U O Ezomike
- Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - D C Okafor
- Paediatric Surgery Unit, Federal Teaching Hospital, Abakaliki, Nigeria
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21
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Sani AM, Arif II, Arshad MM, Mungadi IA, Soh KG, Soh KL. Women With Amenorrhea and Men With Menstruation: The Qualitative Experiences of People With Disorders of Sex Development in Nigeria. J Nurs Res 2019; 28:e67. [PMID: 30855517 DOI: 10.1097/jnr.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) affect the quality of life of people who live with this condition. In developing countries, diagnoses of DSD are associated with a delay in presentation until the patients developed ambiguous physical traits and features. PURPOSE This study explores the menstrual experiences of people with DSD and sex reassignment in Nigeria. METHODS A qualitative approach with a phenomenological study design was employed in this study to explore and describe the experiences of people with DSD at the Usmanu Danfodiyo University Teaching Hospital in Sokoto, Nigeria. The data were collected using face-to-face interviews, transcribed verbatim, and analyzed using NVivo software. RESULTS The findings show that the participants experienced menstrual problems: men with menstruation and women with amenorrhea. The female participants generally described amenorrhea as a disappointment and linked menstruation with womanhood. Amenorrhea evinced both emotional and psychological effects. However, some of the female participants considered amenorrhea in a positive light and were happy with their lives without menstruation. The menstrual experiences of male participants included menarche, lower abdominal pain, regular monthly bleeding, and ovulation. The male participants described menstruation as a disaster in their lives and a source of anxiety, suicidal ideation, and depression. Menstruation negatively affected their psychosocial well-being. CONCLUSIONS The menstrual experience of individuals with DSD negatively affects their quality of life. The women with DSD in this study showed a generally poor knowledge of menarche, menstruation, and puberty, indicating that their parents had ignored the initial symptoms of DSD. DSD were only recognized at puberty because of the development of ambiguous physical traits and of the onset of menstruation in men and the confirmation of amenorrhea in women.
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Affiliation(s)
- Abdurrahman Muhammad Sani
- PhD, RN, FWACN (Fellow West African College of Nursing), Lecturer, Department of Nursing Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
| | - Ismi Ismail Arif
- PhD, Associate Professor, Department of Professional Development and Continuing Education, University Putra Malaysia, Serdang, Selangor State, Malaysia
| | - Mohd Mursyid Arshad
- PhD, Senior Lecturer, Department of Professional Development and Continuing Education, University Putra Malaysia, Serdang, Selangor State, Malaysia
| | - Ismaila Arzika Mungadi
- MBBS, FRCS (Fellow of the Royal College of Surgeons of England), FWACS, Professor, Department of Surgery, Usmanu Danfodiyo University, Sokoto, Nigeria
| | - Kim Geok Soh
- PhD, Associate Professor, Department of Sport Studies, University Putra Malaysia, Serdang, Selangor State, Malaysia
| | - Kim Lam Soh
- PhD, RN, Associate Professor, Department of Nursing and Rehabilitation, University Putra Malaysia, Serdang, Selangor State, Malaysia
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Çetinkaya M, Özen S, Uslu S, Gönç N, Acunas B, Akıncı A, Satar M, Berberoğlu M. Diagnostic and therapeutic approach in newborns with ambiguous genitale with disorder of sex development: consensus report of Turkish Neonatal and Pediatric Endocrinology and Diabetes Societies. TURK PEDIATRI ARSIVI 2018; 53:S198-S208. [PMID: 31236033 PMCID: PMC6568300 DOI: 10.5152/turkpediatriars.2018.01818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Disorders of sex development are defined as conditions in which the chromosomal, gonadal, and anatomic sex is discordant. Patients usually present with atypical appearing genitalia. In the assessment of neonates with disorders of sex development, first, it is important to determine whether this situation requires prompt evaluation, and then the karyotype, hormone levels, and underlying etiology should be determined as soon as possible. All these procedures should be performed in the guidance of a multidisciplinary team in reference centers. As the physical examination of the infant is extremely important, the physcian should suspect and then perform a detailed history and physical examinationi and lastly plan the required laboratory and imaging procedures for the definite diagnosis. It is important not to be hurried in the choice of sex. The aim of this article, which includes the diagnostic and therapeutic approaches in infants with ambiguous genitalia, was to provide a common practice for all pediatricians.
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Affiliation(s)
- Merih Çetinkaya
- Division of Neonatology, Health Sicences University, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Samim Özen
- Division of Pediatric Endocrinology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Sinan Uslu
- Division of Neonatology Health Sicences University, İstanbul Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Nazlı Gönç
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Betül Acunas
- Division of Neonatology, Department of Pediatrics, Trakya University, Faculty of Medicine, Edirne, Turkey
| | - Ayşehan Akıncı
- Division of Pediatric Endocrinology, Department of Pediatrics, İnönü University, Faculty of Medicine, Malatya, Turkey
| | - Mehmet Satar
- Division of Neonatology, Department of Pediatrics, Çukurova University, Faculty of Medicine, Adana, Turkey
| | - Merih Berberoğlu
- Division of Pediatric Endocrinology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
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Gardner M, Sandberg DE. Navigating Surgical Decision Making in Disorders of Sex Development (DSD). Front Pediatr 2018; 6:339. [PMID: 30510925 PMCID: PMC6252317 DOI: 10.3389/fped.2018.00339] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022] Open
Abstract
Surgical management of disorders of sex development (DSD) is associated with contentious debate between and within stakeholder communities. While the intent of surgical management of the genitals and gonads is to benefit the patient physically and psychosocially, these goals have not always been achieved; reports of harm have surfaced. Harm experienced by some patients has resulted in the emergence of an activist platform calling for a moratorium on all surgical procedures during childhood-excepting those forestalling threats to life within the childhood years. This ban is not universally endorsed by patient advocacy groups. Parents, meanwhile, continue to need to make decisions regarding surgical options for their young children. Constructive paths forward include implementation of Consensus Statement recommendations that call for comprehensive and integrated team care, incorporating mental health services, and adopting shared decision making.
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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, Ann Arbor, MI, United States
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24
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Tiryaki S, Tekin A, Yağmur İ, Özen S, Özbaran B, Gökşen D, Darcan Ş, Ulman İ, Avanoğlu A. Parental Perception of Terminology of Disorders of Sex Development in Western Turkey. J Clin Res Pediatr Endocrinol 2018; 10:216-222. [PMID: 29595517 PMCID: PMC6083470 DOI: 10.4274/jcrpe.0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Disorders of sex development (DSD) is a nomenclature intended to defeat the discomfort of families and patients and has found worldwide usage. The aim of this study was to address the perception and usage of terminology among the parents of DSD patients in a tertiary center in western Turkey. METHODS The records of the DSD council (multidisciplinary team where each patient with DSD is discussed) between years 2008-2015 were reviewed retrospectively. Data including details of the management process, patient characteristics and follow-up details were noted. Then inquiries reflecting parental perception about terminology were implemented during clinical visits. RESULTS In total, 121 patients were evaluated in monthly meetings of the DSD council and 79 inquiries were completed. Fifty-one percent of the families admitted knowing the terms DSD, ambiguous genitalia, “dubious genitals” and intersex. However, only 2% preferred using DSD, 6% intersex and 14% ambiguous genitalia. Fifty-two percent of the parents used a disease name in Latin (mostly hypospadias) addressing the disorder. The offspring of 69% of the parents who were familiar with the name “dubious genitals” were diagnosed in the neonatal period. The preferred terminology used by parents was strongly associated with the terminology used most commonly in the medical speciality their child most often attended. CONCLUSION Each country has its own social norms. We suggest therefore that local committees including medical professionals, patients and families should be employed to develop proper terminology.
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Affiliation(s)
- Sibel Tiryaki
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey Phone: +90 533 231 11 91 E-mail:
| | - Ali Tekin
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - İsmail Yağmur
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Burcu Özbaran
- Ege University Faculty of Medicine, Department of Child and Adolescent Psychiatry, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - İbrahim Ulman
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - Ali Avanoğlu
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
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M Selveindran N, Syed Zakaria SZ, Jalaludin MY, Rasat R. Quality of Life in Children with Disorders of Sex Development. Horm Res Paediatr 2018; 88:324-330. [PMID: 28965114 DOI: 10.1159/000478780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Disorders of sex development (DSD) are a heterogeneous group of rare conditions. Evidence-based treatment is challenged by a lack of clinical longitudinal outcome studies. We sought to investigate the quality of life of children with DSD other than congenital adrenal hyperplasia. METHODS The participants (aged 6-18 years) were 23 patients raised as males and 7 patients raised as females. Control data were obtained from representatives of the patients' siblings matched for age and gender. The Pediatric Quality of Life InventoryTM Version 4.0 (PedsQL) Generic Core Scales were used as the study tool. RESULTS In comparison with the reference data, the patient group had significantly lower overall PedsQL (p < 0.01) and school functioning (p < 0.01) scores. Also, the total PedsQL score was significantly lower in patients with DSD who were of female social sex as compared to the controls who were females. Family income, surgical procedures, degree of virilization, and mode of puberty did not influence the PedsQL scores. CONCLUSION This study revealed a poorer quality of life for patients with DSD as compared to the age-matched control group. This highlights the need for a skilled multidisciplinary team to manage this group of patients.
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Affiliation(s)
| | | | | | - Rahmah Rasat
- Department of Paediatrics, University Kebangsaan Malaya Medical Centre, Kuala Lumpur, Malaysia
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Khorashad BS, Khazai B, Roshan GM, Hiradfar M, Afkhamizadeh M, van de Grift TC. Prenatal testosterone and theory of mind development: Findings from disorders of sex development. Psychoneuroendocrinology 2018; 89:250-255. [PMID: 29398092 DOI: 10.1016/j.psyneuen.2017.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/21/2017] [Accepted: 12/12/2017] [Indexed: 01/13/2023]
Abstract
Women on average perform better than men on the "Reading the Mind in the Eyes" test (RMET) which is a measure of Theory of Mind (ToM). The aim of this study was to assess whether these sex differences are influenced by differences in prenatal testosterone levels through a study on individuals with Disorders of Sex Development and matched controls. ToM performance was examined using the RMET in female-assigned-at-birth individuals with increased prenatal testosterone exposure (Congenital Adrenal Hyperplasia (CAH) and 5-alpha Reductase type-2 Deficiency (5α-RD-2)), female-assigned-at-birth individuals with testosterone insensitivity (Complete Androgen Insensitivity Syndrome (CAIS)), and their age-matched unaffected male and female relatives. A total number of 158 individuals participated in the study; 19 with 5α-RD-2, 17 with CAH, 18 women with CAIS, 52 matched unaffected men and 52 matched unaffected women. All subgroups were around 20 years of age. Women with CAH scored significantly lower on RMET than control women and CAIS individuals. CAIS individuals scored significantly higher than control men and participants with 5α-RD. Statistically, CAIS individuals' performance on RMET was similar to control women's, women with CAH did not differ significantly from control men and 5α-RD-2 individuals scored significantly lower than control men. These results, which are in line with previous theories, illustrate that performance on the RMET, as an index of ToM, may be influenced by variations in prenatal androgens levels.
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Affiliation(s)
- Behzad S Khorashad
- Transgender Studies Center, Mashhad University of Medical Sciences, Mashhad, Iran; Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behnaz Khazai
- Transgender Studies Center, Mashhad University of Medical Sciences, Mashhad, Iran; Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Ghasem M Roshan
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehran Hiradfar
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mozhgan Afkhamizadeh
- Endocrine Research Center, Department of Endocrinology, Iman Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Tim C van de Grift
- Department of Medical Psychology (Gender and Sexology), VU University Medical Center, Amsterdam, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Walia R, Singla M, Vaiphei K, Kumar S, Bhansali A. Disorders of sex development: a study of 194 cases. Endocr Connect 2018; 7:364-371. [PMID: 29386228 PMCID: PMC5825923 DOI: 10.1530/ec-18-0022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To study the clinical profile and the management of patients with disorders of sex development (DSD). DESIGN AND SETTING Retrospective study from a tertiary care hospital of North India. METHODS AND PATIENTS One hundred ninety-four patients of DSD registered in the Endocrine clinic of Postgraduate Institute of Medical Education and Research, Chandigarh between 1995 and 2014 were included. RESULTS One hundred and two patients (52.5%) had 46,XY DSD and seventy-four patients (38.1%) had 46,XX DSD. Sex chromosome DSD was identified in seven (3.6%) patients. Of 102 patients with 46,XY DSD, 32 (31.4%) had androgen insensitivity syndrome and 26 (25.5%) had androgen biosynthetic defect. Of the 74 patients with 46,XX DSD, 52 (70.27%) had congenital adrenal hyperplasia (CAH) and eight (10.8%) had ovotesticular DSD. Five patients with sex chromosome DSD had mixed gonadal dysgenesis. Excluding CAH, majority of the patients (90%) presented in the post-pubertal period. One-fourth of the patients with simple virilising CAH were reared as males because of strong male gender identity and behaviour and firm insistence by the parents. Corrective surgeries were performed in twenty patients (20%) of 46,XY DSD without hormonal evaluation prior to the presentation. CONCLUSION Congenital adrenal hyperplasia is the most common DSD in the present series. Most common XY DSD is androgen insensitivity syndrome, while CAH is the most common XX DSD. Delayed diagnosis is a common feature, and corrective surgeries are performed without seeking a definite diagnosis.
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Affiliation(s)
- R Walia
- Department of EndocrinologyPostgraduate Institute of Medical Education & Research, Chandigarh, India
| | - M Singla
- Department of EndocrinologyPostgraduate Institute of Medical Education & Research, Chandigarh, India
| | - K Vaiphei
- Department of HistopathologyPostgraduate Institute of Medical Education & Research, Chandigarh, India
| | - S Kumar
- Department of UrologyPostgraduate Institute of Medical Education & Research, Chandigarh, India
| | - A Bhansali
- Department of EndocrinologyPostgraduate Institute of Medical Education & Research, Chandigarh, India
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Ernst MM, Gardner M, Mara CA, Délot EC, Fechner PY, Fox M, Rutter MM, Speiser PW, Vilain E, Weidler EM, Sandberg DE. Psychosocial Screening in Disorders/Differences of Sex Development: Psychometric Evaluation of the Psychosocial Assessment Tool. Horm Res Paediatr 2018; 90:368-380. [PMID: 30783028 PMCID: PMC6512800 DOI: 10.1159/000496114] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 12/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/AIMS Utilization of a psychosocial screener to identify families affected by a disorder/difference of sex development (DSD) and at risk for adjustment challenges may facilitate efficient use of team resources to optimize care. The Psychosocial Assessment Tool (PAT) has been used in other pediatric conditions. The current study explored the reliability and validity of the PAT (modified for use within the DSD population; PAT-DSD). METHODS Participants were 197 families enrolled in the DSD-Translational Research Network (DSD-TRN) who completed a PAT-DSD during a DSD clinic visit. Psychosocial data were extracted from the DSD-TRN clinical registry. Internal reliability of the PAT-DSD was tested using the Kuder-Richardson-20 coefficient. Validity was examined by exploring the correlation of the PAT-DSD with other measures of caregiver distress and child emotional-behavioral functioning. RESULTS One-third of families demonstrated psychosocial risk (27.9% "Targeted" and 6.1% "Clinical" level of risk). Internal reliability of the PAT-DSD Total score was high (α = 0.86); 4 of 8 subscales met acceptable internal reliability. A priori predicted relationships between the PAT-DSD and other psychosocial measures were supported. The PAT-DSD Total score related to measures of caregiver distress (r = 0.40, p < 0.001) and to both caregiver-reported and patient self-reported behavioral problems (r = 0.61, p < 0.00; r = 0.37, p < 0.05). CONCLUSIONS This study provides evidence for the reliability and validity of the PAT-DSD. Given variability in the internal reliability across subscales, this measure is best used to screen for overall family risk, rather than to assess specific psychosocial concerns.
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Affiliation(s)
- Michelle M. Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Constance A. Mara
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Patricia. Y. Fechner
- Department of Pediatrics, University of Washington, Seattle Children’s DSD Program, Seattle, Washington
| | - Michelle Fox
- Department of Pediatrics, UCLA School of Medicine, Los Angeles, California
| | - Meilan. M. Rutter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Phyllis W. Speiser
- Department of Pediatrics, Cohen Children’s Medical Center of New York and Zucker School of Medicine at Hofstra University, New Hyde Park, New York
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Erica M. Weidler
- Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona; Accord Alliance, Whitehouse Station, New Jersey
| | | | - David E. Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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Phenotypic Variation of 46,XX Late Identified Congenital Adrenal Hyperplasia among Indonesians. J ASEAN Fed Endocr Soc 2018; 33:6-11. [PMID: 33442105 PMCID: PMC7784163 DOI: 10.15605/jafes.033.01.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/09/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives To describe the phenotype variation in Indonesian 46,XX late-identified congenital adrenal hyperplasia (CAH) and the correlation between 17-hydroxyprogesterone (17-OHP) and genital virilization. Methodology Retrospective study of 39 cases with five salt-wasting (SW) and 34 simple virilizing (SV) types. Results The median age of the patients was 9.83 years (range, 0.58 to 44 years) with Prader score 2 to 5. Clitoromegaly (100%) and skin hyperpigmentation (87%) were the most common features. Lack of breast development (Tanner 1 to 2) and menstrual disorders occurred in 9 patients (teenagers and adults). Short stature (6), low voice (14), prominent Adam’s apple (9) and hirsutism (4) were found only in SV types. Rapid growth (7) and precocious puberty (8) were identified in children. Male gender on admission was found in 13 patients. The mean of 17-OHP level was 304.23 nmol/L [standard deviation (SD) 125.03 nmol/L]. There was no correlation between 17-OHP levels and virilization (r=0.19, p>0.05). Conclusion Late-identified CAH showed severe virilization and irreversible sequelae, with clitoromegaly and skin hyperpigmentation as the most commonly seen features. Masculinization of CAH females created uncertainty with regard to sex assignment at birth, resulting in female, male and undecided genders. There is no significant correlation between 17-OHP levels with the degree of virilization in CAH females.
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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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Bangalore Krishna K, Houk CP, Lee PA. Pragmatic approach to intersex, including genital ambiguity, in the newborn. Semin Perinatol 2017; 41:244-251. [PMID: 28535943 DOI: 10.1053/j.semperi.2017.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The evaluation and management of a newborn with ambiguous genitalia must be undertaken as quickly as possible and with great sensitivity for the child's family. Where possible, a comprehensive team approach with a pediatric urologist, endocrinologist, geneticist, neonatologist, and child psychiatrist/psychologist should work closely with the family to establish the diagnosis and determine gender. Although the preferred gender assignment is not always clear, a thorough examination of endocrine function, karyotype, and potential for fertility should guide the determination. While some disorders of sex development (DSD) sex assignments are relatively straightforward, those with more advanced genital ambiguity and unclear gonadal function represent a major challenge. A child's phenotypic sex results from the differentiation of internal ducts and external genitalia under the influence of hormones and transcription factors. Any discordance among these processes results in ambiguous genitalia or DSD. Currently, the main categories of DSD are 46,XX DSD, 46,XY DSD, sex chromosome DSD, ovotesticular DSD, and 46,XX testicular DSD. Priority is given to rule out more immediate life-threatening disorders like salt wasting CAH. Many centers in the United States lack the comprehensive "team members" and not all conditions necessitate this team approach. This article aims to provide guidance for initial workup and identify the specific conditions for which expert guidance is needed.
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Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, 905 West Governor Rd, Suite 300, Hershey, PA 17033-0850.
| | | | - Peter A Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, 905 West Governor Rd, Suite 300, Hershey, PA 17033-0850
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Zainuddin AA, Mahdy ZA. The Islamic Perspectives of Gender-Related Issues in the Management of Patients With Disorders of Sex Development. ARCHIVES OF SEXUAL BEHAVIOR 2017; 46:353-360. [PMID: 27102604 PMCID: PMC5272885 DOI: 10.1007/s10508-016-0754-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 12/11/2015] [Accepted: 03/31/2016] [Indexed: 06/04/2023]
Abstract
In Islam, the person with somatic sex ambiguity due to a disorder of sex development (DSD), such as 46,XX congenital adrenal hyperplasia or 46,XY androgen insensitivity, is recognized as khunsa. Two types of khunsa are distinguished: wadhih (discernible) and musykil (intractable). A recent fatwa (religious edict) in Malaysia decreed that it is permissible for male-assigned patients from these two groups to have gender reassignment surgery to female following diagnosis; however, the religious authority has yet to rule on the reassignment from female to male, if requested. The different schools of law in Islam agree on some aspects of gender-related issues like the position of khunsa in prayer congregations, but differ in their opinions on others such as property inheritance and bathing rituals. For purposes of illustration, this article includes three case reports on Muslim patients with DSD in Malaysia, focusing on issues of gender assignment: (1) a patient with 46,XX CAH, assigned as female, requesting reassignment to male; (2) a patient with 46,XX CAH, assigned female, and gender dysphoric, but undecided on the gender to be; and (3) a patient with 46,XY complete gonadal dysgenesis, raised female due to her phenotype at birth, diagnosed late, at age 18 years, and content to remain female. Gender-related issues from the perspective of Islamic jurisprudence are highlighted and discussed. To ensure holistic care, health-service providers involved in the care of Muslim patients with DSDs need to be aware of the Islamic perspectives on gender-related issues and involve expert religious authorities.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics & Gynaecology, Faculty of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia.
| | - Zaleha Abdullah Mahdy
- Department of Obstetrics & Gynaecology, Faculty of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
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Ediati A, Juniarto AZ, Birnie E, Okkerse J, Wisniewski A, Drop S, Faradz SMH, Dessens A. Social stigmatisation in late identified patients with disorders of sex development in Indonesia. BMJ Paediatr Open 2017; 1:e000130. [PMID: 29637149 PMCID: PMC5862183 DOI: 10.1136/bmjpo-2017-000130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/21/2017] [Accepted: 08/22/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess social stigmatisation related to atypical appearance of the body, including, but not limited to the external genitalia, among Indonesian patients with a disorder of sex development (DSD). Until recently, diagnostic evaluation, information about the underlying causes of DSD and treatment options were sparsely available for these patients. METHODS Eighty-one parents of children and adolescents with DSD (aged 6-17 years) and 34 adult patients with DSD (aged 18-41 years) completed the Social Stigmatisation Scale towards DSD, an instrument developed to assesses the frequency of stigmatisation and the level of stress associated with these experiences. Open-ended questions investigated detailed information on stigmatisation as well as parents' and patients' emotional and behavioural reactions to these experiences. Differences in stigmatisation were explored across sex of rearing, gender change history, treatment status and DSD characteristics that could be easily identified by others (e.g., masculinisation of the body in women). RESULTS Social stigmatisation was reported by patients with atypical appearance of their genitalia, atypical appearance of their body aside from their genitals, among those who displayed cross-gender behaviour and those who changed gender. Among participants reared as women and among children and adolescents who changed gender, social stigmatisation was associated with ostracism, depressive symptoms and social isolation. CONCLUSIONS Patients unable to conceal their condition (those with visible physical atypicality and those who changed gender) experienced social stigmatisation. Stigmatisation was stressful and related to isolation and withdrawal from social interaction. Education about DSD, self-empowerment and medical interventions to prevent atypical physical development may remove barriers to acceptance by others for affected individuals.
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Affiliation(s)
- Annastasia Ediati
- Faculty of Psychology, Diponegoro University, Semarang, Indonesia.,Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia
| | - A Zulfa Juniarto
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia.,Dr. Kariadi Hospital, Semarang, Indonesia
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jolanda Okkerse
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Amy Wisniewski
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Stenvert Drop
- Department of Pediatrics, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Sultana M H Faradz
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia
| | - Arianne Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC Sophia, Rotterdam, The Netherlands
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M. Selveindran N, Syed Zakaria SZ, Jalaludin MY, Rasat R. Behavioural Problems in Children with 46XY Disorders of Sex Development. Int J Endocrinol 2017; 2017:5987490. [PMID: 28717365 PMCID: PMC5498928 DOI: 10.1155/2017/5987490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/31/2017] [Accepted: 04/19/2017] [Indexed: 11/17/2022] Open
Abstract
The aim of this study is to determine the behavioural problems of children with 46XY disorders of sex development (DSD) with genital ambiguity and to identify the risk factors that may influence behaviour. The 27 participants (aged 6-18 years) consisted of 21 patients raised as boys and 6 patients raised as girls. Control data were obtained from a representative sibling of each patient who was matched for age and gender. The study tool used was the Child Behaviour Checklist (CBCL), which is a parent-administered questionnaire. The analysis of the behavioural scores revealed that the patient group had poorer scores in the total, externalizing, and internalizing realms. This group also had poorer scores in the anxious-depressed, social, and rule-breaking realms as compared to the control group. In addition, the XY-F group had higher scores (more pathological) than the XY-M group, although the difference in the scores was not statistically significant. A comparison of the prevalence of patients with scores in the clinical range with that of the control group was not statistically significant. These findings support the current recommendations that psychological counselling should be an integral part of the professional support offered to patients with DSD.
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Affiliation(s)
- Nalini M. Selveindran
- Department of Paediatrics, Hospital Putrajaya, Pusat Pentadbiran Putrajaya, Presint 7, 62250 Putrajaya, Malaysia
- *Nalini M. Selveindran:
| | - Syed Zulkifli Syed Zakaria
- Department of Paediatrics, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak Cheras, 56000 Kuala Lumpur, Malaysia
| | | | - Rahmah Rasat
- Department of Paediatrics, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak Cheras, 56000 Kuala Lumpur, Malaysia
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Meyer-Bahlburg HFL, Baratz Dalke K, Berenbaum SA, Cohen-Kettenis PT, Hines M, Schober JM. Gender Assignment, Reassignment and Outcome in Disorders of Sex Development: Update of the 2005 Consensus Conference. Horm Res Paediatr 2016; 85:112-8. [PMID: 26727471 DOI: 10.1159/000442386] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/10/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Societal changes are increasingly moving the conceptualization of gender from a set of binary categories towards a bimodal continuum, which along with the cautious conclusions resulting from the 2005 Consensus Conference influences gender-related clinical work with patients with disorders of sex development. OBJECTIVE This article provides an update of these developments over the past decade along with an overview of pertinent new data. CONCLUSION Considerably more research is needed on larger sample sizes with systematic long-term follow-up to ground the emerging trends in clinical management of the highly diverse disorders of sex development syndromes in a solid empirical basis.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute and Department of Psychiatry, College of Physicians & Surgeons of Columbia University, New York, N.Y., USA
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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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Juniarto AZ, van der Zwan YG, Santosa A, Ariani MD, Eggers S, Hersmus R, Themmen APN, Bruggenwirth HT, Wolffenbuttel KP, Sinclair A, White SJ, Looijenga LHJ, de Jong FH, Faradz SMH, Drop SLS. Hormonal evaluation in relation to phenotype and genotype in 286 patients with a disorder of sex development from Indonesia. Clin Endocrinol (Oxf) 2016; 85:247-57. [PMID: 26935236 DOI: 10.1111/cen.13051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 01/22/2016] [Accepted: 02/28/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this study was to determine the aetiological spectrum of disorders of sex development (DSD) in a large cohort of underprivileged and undiagnosed patients from Indonesia. METHODS A total of 286 patients with atypical external and/or internal genitalia were evaluated using clinical, hormonal, molecular genetic and histological parameters. RESULTS The age (years) at presentation was 0-0·5 in 41 (14·3%), >0·5-12 in 181 (63·3%) and >12 in 64 cases (22·4%). 46,XY DSD was most common (68·2%, n = 195), 46,XX DSD was found in 23·4% (n = 67) and sex chromosomal DSD in 8·4% (n = 24). In 61·2% of 46,XX DSD patients, 17·9% of 46,XY DSD patients and all sex chromosome DSD patients (29·4% in total), a final diagnosis was reached based on genetic or histological gonadal tissue evaluation. 17-hydroxyprogesterone and androstenedione levels were the most distinctive parameters in 46,XX DSD patients. In 46,XY DSD, diagnostic groups were identified based on the external masculinization score: androgen action disorder (AAD), unknown male undermasculinization (UMU), and gonadal dysgenesis (GD). LH, FSH and testosterone levels were most informative especially in the older age group. HCG tests were of no additional value as no patients with androgen synthesis disorders were found. Hormonal profiles of patients with sex chromosome DSD and a Y-chromosome sequence containing karyotype showed high levels of LH and FSH, and low levels of AMH, inhibin B and testosterone compared with the normal male range. Gene mutations were found in all patients with CAH, but in only 24·5% and 1·8% of patients with AAD and UMU. In 32% of 46,XY GD patients, copy number variants of different genes were found. CONCLUSION A stepwise diagnostic approach led to a molecularly or histologically proven final diagnosis in 29·4% of the patients. The most informative parameters were serum levels of 17-hydroxyprogesterone and androstenedione in 46,XX DSD patients, and serum LH, FSH and testosterone levels in 46,XY DSD patients.
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Affiliation(s)
- A Zulfa Juniarto
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Yvonne G van der Zwan
- Department of Paediatrics, Division of Endocrinology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ardy Santosa
- Department of Urology, Dr Kariadi Hospital, Semarang, Indonesia
| | - Mahayu Dewi Ariani
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Stefanie Eggers
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Remko Hersmus
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Axel P N Themmen
- Department of Internal Medicine, Section of Endocrinology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hennie T Bruggenwirth
- Department of Clinical Genetics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Paediatric Urology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Andrew Sinclair
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Stefan J White
- Centre for Genetic Diseases, MIMR-PHI Institute of Medical Research, Monash University, Clayton, Australia
| | - Leendert H J Looijenga
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank H de Jong
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Sultana M H Faradz
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Stenvert L S Drop
- Department of Paediatrics, Division of Endocrinology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Machado PS, Costa AB, Nardi HC, Fontanari AMV, Araujo IR, Knauth DR. Follow-up of psychological outcomes of interventions in patients diagnosed with disorders of sexual development: A systematic review. J Health Psychol 2016; 21:2195-206. [DOI: 10.1177/1359105315572454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The objective of this study was to perform a systematic review of articles that followed up the psychological outcomes of interventions in patients with disorders of sexual development. The analysis focused on the methodological quality of the studies and the assumptions on the evaluation of the intervention outcomes. The review signaled the need for better consideration about the complexity of intersexuality and for a shift from the anatomical/functional/aesthetic to the subjective outcomes related to patient’s quality of life. Furthermore, it is suggested that the interventions should be better investigated, given the lack of evidence for the necessity of early procedures.
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Abstract
This article is intended to illuminate several important changes in our concept of gender-specific medicine in the genomic era. It reviews the history of gender-specific medicine, pointing out the changes in our perception of the nature of biological sex and our expanding knowledge of how it affects the phenotype. The old debate about 'nature versus nurture' is now largely resolved; the two are inextricably intertwined as a result of epigenomic regulation of gene expression; many of the resulting phenotypic changes are inherited and affect future generations. More accurate, rapid and cheaper methods of editing genomic composition are implementing a more sophisticated understanding of how genes function and how individual components of the genome might be added or eliminated to maintain health and prevent disease. As Venter predicted, the new discipline of synthetic biology, based on the creation and use of novel 'designer' chromosomes is an inevitable expansion of our ability to decipher the naturally occurring genome and the factors that control its expression. As we move with unexpected and stunning rapidity into our exploration and manipulation of the genetic code, our investigations must acknowledge the solidly established fact that biological sex will have a profound impact on the interventions we have made and will make in the future. Unfortunately, in spite of the recent urging of the National Institutes of Health (NIH) that sex be included as an essential variable in all levels of scientific investigation, genuine issues remain to be resolved before all scientists accept not only the importance of doing this, but also how to implement it.
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Odundo GO, Ngwiri T, Otuoma O, Laigong P, Mukhwana R, Limbe MS, Chanzu NM. The Impact and Successes of a Paediatric Endocrinology Fellowship Program in Africa. Int J Endocrinol 2016; 2016:1560248. [PMID: 26904118 PMCID: PMC4745291 DOI: 10.1155/2016/1560248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/24/2015] [Indexed: 12/29/2022] Open
Abstract
Background. The prevalence and distribution of endocrine disorders in children in Africa are not well known because most cases are often undiagnosed or diagnosed too late. The awareness of this led to the launch of the Paediatric Endocrinology Training Center for Africa (PETCA) designed to improve quality and access to health care by training paediatricians from Africa in paediatric endocrinology. Methods. The fellowship is undertaken over an 18-month period: six months of clinical and theoretical training in Kenya, nine months of project research at the fellow's home country, and three months of consolidation in Kenya. Upon completion, certified paediatricians are expected to set up centers of excellence. Results. There have been two phases, phase I from January 2008 to October 2012 and phase II from January 2012 to April 2015. Fifty-four fellows from 12 African countries have been certified, 34 (phase I) and 20 (phase II). Over 1,000 patients with wide ranging diabetes and endocrine disorders have been diagnosed and treated and are being followed up at the centers of excellence. Conclusion. The successes of the PETCA initiative demonstrate the impact a capacity building and knowledge transfer model can have on people in resource-poor settings using limited resources.
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Affiliation(s)
- Gordon Otieno Odundo
- Gertrude's Children's Hospital, P.O. Box 42325, Nairobi 00100, Kenya
- *Gordon Otieno Odundo:
| | - Thomas Ngwiri
- Gertrude's Children's Hospital, P.O. Box 42325, Nairobi 00100, Kenya
| | - Olivia Otuoma
- Gertrude's Hospital Foundation, Gertrude's Children's Hospital, P.O. Box 42325, Nairobi 00100, Kenya
| | - Paul Laigong
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 460, Nairobi 00202, Kenya
| | - Renson Mukhwana
- Gertrude's Children's Hospital, P.O. Box 42325, Nairobi 00100, Kenya
| | - Mary Slessor Limbe
- Department of Paediatrics and Child Health, Aga Khan University, P.O. Box 30270, Nairobi 00100, Kenya
| | - Nadia Musimbi Chanzu
- Institute of Child Health and Research, Gertrude's Children's Hospital, P.O. Box 42325, Nairobi 00100, Kenya
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AboElella SS, Tawfik MA, Abo El-fotoh WMM. Molecular study of developmental sex disorders in children. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2015. [DOI: 10.1016/j.ejmhg.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ediati A, Juniarto AZ, Birnie E, Drop SLS, Faradz SMH, Dessens AB. Gender Development in Indonesian Children, Adolescents, and Adults with Disorders of Sex Development. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1339-1361. [PMID: 25813609 DOI: 10.1007/s10508-015-0493-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/08/2014] [Accepted: 10/04/2014] [Indexed: 06/04/2023]
Abstract
In most Western countries, clinical management of disorders of sex development (DSD), including ambiguous genitalia, begins at diagnosis soon after birth. For many Indonesian patients born with ambiguous genitalia, limited medical treatment is available. Consequently, affected individuals are raised with ambiguous genitalia and atypical secondary sex characteristics. We investigated gender identity and gender role behavior in 118 Indonesian subjects (77 males, 41 females) with different types of DSD in comparison with 118 healthy controls matched for gender, age, and residential setting (rural, suburban, or urban). In Study 1, we report on methodological aspects of the investigation, including scale adaptation, pilot testing, and determining reliability and validity of measures. In Study 2, we report on gender development in 60 children (42 boys, 18 girls), 24 adolescents (15 boys, 9 girls), and 34 adults (19 men, 15 women) with DSD. The majority of participants with DSD never received any medical or surgical treatment prior to this study. We observed a gender change in all age groups, with the greatest incidence in adults. Among patients who changed, most changed from female to male, possessed a 46,XY karyotype, and had experienced significant masculinization during life. Gender identity confusion and cross-gender behavior was more frequently observed in children with DSD raised as girls compared to boys. Puberty and associated masculinization were related to gender problems in individuals with 46,XY DSD raised female. An integrated clinical and psychological follow-up on gender outcome is necessary prior to puberty and adulthood.
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Affiliation(s)
- Annastasia Ediati
- Department of Clinical Psychology, Faculty of Psychology, Diponegoro University, Tembalang, Semarang, 50275, Indonesia,
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Mohamed MS, Noor SNM. Islamic bioethical deliberation on the issue of newborns with disorders of sex development. SCIENCE AND ENGINEERING ETHICS 2015; 21:429-440. [PMID: 24664170 DOI: 10.1007/s11948-014-9534-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/17/2014] [Indexed: 06/03/2023]
Abstract
This article presents the Islamic bioethical deliberation on the issue of sex assignment surgery (SAS) for infants with disorders of sex development (DSD) or intersexed as a case study. The main objective of this study is to present a different approach in assessing a biomedical issue within the medium of the Maqasid al-Shari'ah. Within the framework of the maqasidic scheme of benefits and harms, any practice where benefits are substantial is considered permissible, while those promoting harms are prohibited. The concept of Maqasid al-Shari'ah which is the mechanistic interpretation of Qur'an and Hadith presents the holistic attention of Islam on many life activities, including healthcare. Indeed, this concept encompasses many aspects of worldly life, both for the human individual and collectively for the whole society. In healthcare, the practice of SAS on DSD newborns has presented an assortment of implications on the future livelihood of the affected individual. The process of decision-making seems to be very multifaceted since every element such as the determination of the 'correct' sex and the urgency of early surgery must consider the benefits and harms, as well as the child's rights and best interest. The application of the concept of Maqasid al-Shari'ah, would convey a pragmatic approach that is often disregarded in Western medicine. This approach considers the right of the individual to live life optimally, individually and socially and practice his faith, precisely, in accordance with the assigned gender.
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Affiliation(s)
- Mohd Salim Mohamed
- Department of Science and Technology Studies, Faculty of Science, University of Malaya, 50603, Kuala Lumpur, Malaysia,
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Abstract
Disorders of sex development (DSDs) continue to present many challenges. A clear consensus among clinicians has emerged in paediatric care; however, the same cannot be said of adult care services. Moreover, transition to adult care is a process that takes many years. Although evidence-based models of transitional care do exist in other medical specialities, few studies have been conducted in adolescents with DSDs, and a clear and pressing need exists for further research to guide the care of these patients. A general move towards independence and self-responsibility is common to all transition programmes, but specific issues for those with a DSD include disclosure, genital examinations and potential vaginal treatments. Psychological support underpins the whole transition process for patients with a DSD and encourages an individual approach to develop. In this Perspectives article, we describe the barriers to successful transition in this setting and outline suggestions to overcome them.
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Affiliation(s)
- Naomi S Crouch
- Department of Women's Health, St Michael's Hospital, Southwell Street, Bristol BS2 8EG, UK
| | - Sarah M Creighton
- University College London Hospitals, Department of Women's Health, 250 Euston Road, London NW1 2PG, UK
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45
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Gender identity shows a high correlation with Prader score in patients with disorders of sex development (DSD) presenting in mid childhood. Pediatr Surg Int 2014; 30:527-32. [PMID: 24566723 DOI: 10.1007/s00383-014-3486-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE In developing countries like Bangladesh, delayed presentation for disorders of sex development (DSD) is common, and provides some special problems for management. There remains significant controversy about appropriate sex assignment in this group. We aimed, therefore, to assess gender identity (GI) in 50 consecutive patients with DSD presenting to a referral centre in Chittagong, Bangladesh, and correlate it with Prader score, to see if the latter could be used to predict GI. METHODS A cross-sectional, case-control study of 50 consecutive children with DSD and 50 children with vascular anomalies was conducted in the Pediatric Surgical Clinic, Chittagong Medical College and Hospital. After informed consent, patients and controls provided oral answers to a GI questionnaire and had a detailed history and physical examination. Sex-typed activities were assessed by observations of a structured toy play and the child's selection of a toy to keep. Both patients and parents then completed the Child Game Participation Questionnaire. RESULTS There were no differences in age (2-16 years, mean 8.74) between controls and DSD patients (11 46, XX DSD, 32 46, XY DSD, 4 MGD, 3 ovo-testicular DSD). Fifteen of the DSD patients (30 %) came from consanguineous marriages and only 2 of the control patients had consanguinity of their parents. For the 13-question GI interview, there was no overall difference between DSD cases and controls. For the 46, XX DSD subgroup, there was a significantly higher score (11.1 ± 7.1) compared with control girls (4.5 ± 4.7) (p < 0.05), while for DSD and control boys, there was a positive correlation with age and GI (p < 0.01). Prader score correlated with GI score in both control (r = 0.91) and DSD patients (r = 0.75) (p < 0.01), DSD girls played significantly less with girls' toys than controls (p < 0.01), but there was no differences for the boys. Composite scores on GI and gender-related behaviour correlated with Prader score for DSD patients (r = 0.61) (p < 0.01). CONCLUSION This study supports the view that GI and gender-role behaviour should be assessed routinely in DSD patients presenting after the neonatal period, so that sex assignment is in accordance with behaviour. Prader scores showed a good correlation with GI and gender role behaviour.
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Abstract
BACKGROUND Cross-cultural differences in attitudes and practices related to diabetes are well-known. Similar differences in symptom reporting of endocrine conditions such as menopause are well documented. Minimal literature is available on the cross-cultural variation in reporting of hypoglycemic symptoms. AIMS This cross-sectional study aimed to assess the symptoms of hypoglycemia encountered by diabetologists who deal with patients from different language groups from various states of North and West India and Nepal. MATERIALS AND METHODS Eighty three doctors from six Indian states and Nepal, attending a continuing medical education program were requested to fill a detailed, pre-tested, Likert scale based questionnaire which assessed the frequency and symptoms with which patients presented with hypoglycemia in their clinical practice. Data were analyzed based on geographic location of the diabetologists and language spoken by their patients (Hindi vs. Gujarati). RESULTS Gujarati-speaking patients tended to report to their doctors, a greater inability to work under pressure and a higher frequency of intense hunger during hypoglycemia. They were less likely to report specific adrenergic (inward trembling), neuroglycopenic (feeling down over nothing), and nocturnal (crumpled bedsheets upon waking up) symptoms. CONCLUSION Significant cross-cultural differences related to the symptomatology of hypoglycemia are noted. Indian diabetologists should be aware of the varying presentation of hypoglycemia based on language and ethnic background.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and B.R.I.D.E, Karnal, Haryana, India
| | | | - Ambrish Mithal
- Department of Endocrinology, Medanta Hospital, Gurgaon, India
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Zainuddin AA, Grover SR, Shamsuddin K, Mahdy ZA. Research on quality of life in female patients with congenital adrenal hyperplasia and issues in developing nations. J Pediatr Adolesc Gynecol 2013; 26:296-304. [PMID: 23507003 DOI: 10.1016/j.jpag.2012.08.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 07/30/2012] [Accepted: 08/07/2012] [Indexed: 11/16/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is the commonest cause of ambiguous genitalia for female newborns and is one of the conditions under the umbrella term of "Disorders of Sex Development" (DSD). Management of these patients require multidisciplinary collaboration and is challenging because there are many aspects of care, such as the most appropriate timing and extent of feminizing surgery required and attention to psychosexual, psychological, and reproductive issues, which still require attention and reconsideration, even in developed nations. In developing nations, however, additional challenges prevail: poverty, lack of education, lack of easily accessible and affordable medical care, traditional beliefs on intersex, religious, and cultural issues, as well as poor community support. There is a paucity of long-term outcome studies on DSD and CAH to inform on best management to achieve optimal outcome. In a survey conducted on 16 patients with CAH and their parents in a Malaysian tertiary center, 31.3% of patients stated poor knowledge of their condition, and 37.5% did not realize that their medications were required for life. This review on the research done on quality of life (QOL) of female patients with CAH aims: to discuss factors affecting QOL of female patients with CAH, especially in the developing population; to summarize the extant literature on the quality of life outcomes of female patients with CAH; and to offer recommendations to improve QOL outcomes in clinical practice and research.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
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Ediati A, Juniarto AZ, Birnie E, Drop SLS, Faradz SMH, Dessens AB. Body image and sexuality in Indonesian adults with a disorder of sex development (DSD). JOURNAL OF SEX RESEARCH 2013; 52:15-29. [PMID: 24144298 DOI: 10.1080/00224499.2013.816260] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In Indonesia, disorders of sex development (DSDs) are not well recognized and medical care for affected individuals is scarce. Consequently, many patients live with ambiguous genitalia and appearance. We compared reported outcomes on body image, sexual functioning, and sexual orientation of 39 adults with DSDs (aged 18 to 41) and 39 healthy controls matched for gender, age, and residential setting (urban, suburban, rural). Differences in gender and treatment status (treated or untreated) were also explored. On body image, adults with DSDs reported dissatisfaction with sex-related body parts. Compared to the matched controls, women with DSDs reported greater sexual distress, and men with DSDs reported lower erectile and ejaculation frequencies, and more dissatisfaction with sexual life but not with sexual desire and activities. Men with DSDs who had undergone genital surgery reported higher erectile and ejaculation frequencies than untreated men. More women than men in the DSDs group reported a nonexclusive heterosexual orientation. DSDs and infertility had a great impact on sexuality. Fear of ostracism complicated DSD acceptance. Findings were compared to those of Western studies. Based on these results, education about DSDs and their psychosexual consequences may help reduce the sexual distress and problems in adults with DSDs and improve quality of life.
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Affiliation(s)
- Annastasia Ediati
- a Department of Clinical Psychology, Faculty of Psychology , Diponegoro University
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Zacharin M, Chanoine JP, Cassorla F, Brink S, Hanas R, Fideleff HL, Oduwole A, Shah N, Hochberg Z. Promoting excellence in the care of pediatric endocrine diseases in the developing world. Pediatrics 2013; 131:e573-8. [PMID: 23339226 DOI: 10.1542/peds.2012-0848] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
On behalf of the Global Pediatric Endocrinology and Diabetes group, the authors provide a perspective on the rights of a child as enshrined in the United Nations Convention on the Rights of the Child (1989) concerning the care of pediatric endocrine disorders and diabetes mellitus, throughout the world, with particular reference to care in resource-constrained settings. In this article, we define the spectrum of health care needs of the child with an endocrine disorder and how they may be addressed, in terms of education, research, and development of sustainable programs for improved health outcomes. We emphasize the responsibilities of medical communities, the pharmaceutical industry, and relevant governments in promoting and supporting such concepts.
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Affiliation(s)
- Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, Victoria 3052, Australia.
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50
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Zhu D, Hu L, Wan X, Li H, You Q, Gao L, Feng J. Quality of life evaluation in juveniles with disorders of sexual development. Pediatr Surg Int 2012; 28:1119-23. [PMID: 23053598 DOI: 10.1007/s00383-012-3182-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the quality of life of 6-11-year-old children and 12-17-year-old adolescents with disorders of sexual development (DSDs) following reparative surgery. METHODS Fifty pediatric patients with DSDs, including 32 cases of congenital adrenal hyperplasia, 2 cases of complete androgen insensitivity syndrome, 1 case of partial androgen insensitivity syndrome, 6 cases of complete testicular dysgenesis, 7 cases of partial testicular dysgenesis, and 2 cases of ovotesticular DSD, with complete follow-up data, were recruited. Healthy control subjects (matched for age, gender, and living environment) served as controls. Physical, socio-emotional, and psychological evaluations were performed. RESULT Among 50 patients, eight boys and two girls (designated by social gender) were unsatisfied with the morphology of their external genitalia. Social limitations were observed in 4/8 (50 %) of the boys and in 12/42 (28.6 %) of the girls. Psychological problems were significantly more prevalent in the DSD group than in the control group (p < 0.05). CONCLUSIONS The quality of life of pediatric patients with DSDs was impaired to varying degrees following reparative surgery.
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Affiliation(s)
- Dan Zhu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
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