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Fernandez N, Zuluaga L, Perez MF, Perez J, Cespedes C, Forero C, Orjuela C, Suarez F. Interpretación medicolegal para el abordaje de individuos con desórdenes del desarrollo sexual en Colombia. Rev Urol 2021. [DOI: 10.1055/s-0041-1740376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Resumen
Objetivo Los desórdenes del desarrollo sexual (DDSs) son un grupo de condiciones médicas cuyo manejo implica un enfoque transdisciplinario. En la legislación colombiana, no existe una regulación específica en materia de intervenciones médicas en individuos con DDSs. La Corte Constitucional Colombiana se ha encargado de proferir sentencias, en las cuales se han establecido unos lineamientos y parámetros para el manejo jurídico de los casos de ambigüedad genital.Teniendo en cuenta lo anterior, nos proponemos en este artículo exponer y analizar, desde la visión de un grupo transdisciplinario, las sentencias más relevantes que han sido proferidas por la Corte Constitucional Colombiana.
Métodos Se realizó una revisión narrativa en las bases de datos de la Corte Constitucional y de la literatura legal. Se recopilaron todas las sentencias disponibles, y se evaluaron lo casos clínicos identificados por el grupo transdisciplinario de DDSs del Hospital Universitario San Ignacio. Finalmente, los autores generaron por consenso un texto de discusión, como guía para los lectores, luego de analizar cada una de las sentencias y los casos presentados.
Resultados Se identificaron 9 sentencias y los antecedentes que llevaron a la elaboración de cada una de ellas. Los nueve casos presentados contienen conceptos importantes para la articulación por parte del grupo transdisciplinario, tales como, autonomía, consentimiento sustituto y asistido, e indicación médica del tratamiento. Se excluyeron las sentencias T-692/99 y la T-918/2012, dado que daban información duplicada con referencia a sentencias incluidas en este documento.
Conclusión La Corte Constitucional Colombiana ha proferido sentencias en las cuales no se ha contado con la participación de grupos de expertos. La terminología usada no describe apropiadamente el lenguaje técnico que se aplica al manejo de nuestros pacientes. Para el abordaje de individuos con DDSs, resulta muy importante conocer la relevancia de las sentencias basadas en un análisis individual de cada caso.
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Affiliation(s)
- Nicolas Fernandez
- Seattle Children's Hospital, University of Washington, Seattle, United States
| | - Laura Zuluaga
- Department of Urology, Fundacion Santa Fe De Bogota, Andes University, Bogota, Colombia
| | - Maria Fernanda Perez
- Comité de Ética en Investigación con Seres Humanos, Riesgo y fractura S. A., Cayre, Universidad Javeriana, Bogota, Colombia
| | - Jaime Perez
- Department of Urology, Fundacion Santa Fe De Bogota, Andes University, Bogota, Colombia
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Camila Cespedes
- Division of Pediatric Endocrinology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Catalina Forero
- Division of Pediatric Endocrinology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Camilo Orjuela
- Pediatric Urology, Universidad Nacional, Bogota, Colombia
| | - Fernando Suarez
- Instituto de Genetica Humana, Pontificia Universidad Javeriana, Bogota, Colombia
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Hou L, Zhao M, Fan L, Cao B, Chen J, Cui Y, Polak M, Gong C. One hundred twelve cases of 46, XY DSD patients after initial gender assignment: a short-term survey of gender role and gender dysphoria. Orphanet J Rare Dis 2021; 16:416. [PMID: 34627348 PMCID: PMC8501610 DOI: 10.1186/s13023-021-02039-1] [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] [Received: 05/13/2021] [Accepted: 09/19/2021] [Indexed: 11/25/2022] Open
Abstract
Background 46, XY disorders of sex development (46, XY DSD) are congenital disorders with 46, XY chromosomal karyotype but inconsistent gonadal/phenotypic sex. One of the biggest concerns for parents and clinicians is the gender assignment. However, there is no standard uniform of care nor consensus at present. We sought to evaluate the current treatment's rationality and provide a reference basis for the gender reassignment in 46, XY DSD patients with a specific diagnosis. Methods We conducted a cross-sectional survey of gender role with the Pre-school Activities Inventory (PSAI), the Children's Sex Role Inventory (CSRI) in 46, XY DSD patients and set up control groups comparison. Psychiatrist assessed gender dysphoria in patients ≥ 8-year-old with the criteria of diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). Results A total of 112 responders of 136 patients participated in this study (82.4%, aged 2–17.8 years, median age: 4-year-old). The follow-up period was from 6 months to 10 years (median: 2 years). Twenty-five females were reassigned to the male gender after a specific diagnosis (16/25 (64%) in 5 alfa-reductase-2 deficiency (5α-RD2), 5/25 (20%) in partial androgen insensitivity syndrome (PAIS), 4/25 (16%) in NR5A1gene mutation). Male gender assignment increased from 55.3 (n = 62) to 77.7% (n = 87). The median PSAI score was similar to the control males in 5α-RD2, PAIS, and NR5A1 gene mutation groups (p > 0.05); while identical to the control females in complete androgen insensitivity syndrome (CAIS) and CYP17A1 gene mutation groups (p > 0.05). PSAI score of children raised as male was higher than those of CAIS and CYP17A1 groups raised as female (p < 0.05). CSRI scale showed no statistical differences in the consistency of gender roles and reassigned gender between 46, XY DSD patients and control groups (p > 0.05). None of the patients over 8-year-old (n = 44) had gender dysphoria. Conclusion The reassigned gender in 46, XY DSD patients is consistent with their gender role during early childhood. None of them had gender dysphoria. The molecular diagnosis, gonadal function, and the gender reassignment are congruent within our Chinese cohort. Long-term follow-up and more evaluation are still required.
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Affiliation(s)
- Liping Hou
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen, 518038, China
| | - Ming Zhao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Lijun Fan
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jiajia Chen
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yonghua Cui
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Michel Polak
- Pediatric Endocrinology Diabetology and Gynaecology, Hôpital Universitaire Necker Enfants-Malades, AP-HP, Paris, France
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HFL, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:336-350. [PMID: 33343244 DOI: 10.1176/appi.focus.18304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Copyright © William Byne et al. 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.).
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Meyer-Bahlburg HFL. "Diagnosing" Gender? Categorizing Gender-Identity Variants in the Anthropocene. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:2027-2035. [PMID: 30607711 DOI: 10.1007/s10508-018-1349-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 05/26/2023]
Abstract
In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia-usually designed for one of the traditional sexes-typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- Department of Psychiatry, NYS Psychiatric Institute, Vagelos College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
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Sevlever M, Meyer-Bahlburg HFL. Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1993-2001. [PMID: 30604171 DOI: 10.1007/s10508-018-1362-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 05/12/2023]
Abstract
The rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
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Affiliation(s)
- Melina Sevlever
- Department of Psychiatry, Neurological Institute, Columbia University Irving Medical Center, 710 West 168th Street, 12th Floor, New York, NY, 10032, USA.
| | - Heino F L Meyer-Bahlburg
- Department of Psychiatry/NYS Psychiatric Institute, Vagelos College of Physicians, Surgeons of Columbia University, New York, NY, USA
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Psychological perspectives to early surgery in the management of disorders/differences of sex development. Curr Opin Pediatr 2019; 31:570-574. [PMID: 31246626 DOI: 10.1097/mop.0000000000000784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The review focuses on genitoplasty, performed on young children with disorders/differences of sex development (DSD) to 'typify' ambiguous external genitalia and intended to result in either male or female-appearing genitals. Consensus on whether or not early genitoplasty is optimal or appropriate has yet to be achieved. This article reviews arguments in favor of early surgery as well as those disputing their justification. RECENT FINDINGS Arguments supporting early genitoplasty include the assumption that a child's genital anatomy should match their gender of rearing for optimal psychosocial development and that outcomes are better physically and psychologically than when surgery is deferred. Those disputing their justification argue that they deny patients the right to participate in irreversible decisions related to anatomy and gender, revoke the possibility of an open future, and violate basic human rights. Clinical management includes recommendations for interdisciplinary care integrating psychologists, and shared decision-making processes to assist families in carefully considering options. SUMMARY Early genital surgery in DSD care is controversial with compelling arguments put forth by both proponents and opponents. Relevant issues can be examined from ethical, psychological, cultural and medical perspectives - all of which need to be accounted for in both research and standard of care development.
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Hemesath TP, de Paula LCP, Carvalho CG, Leite JCL, Guaragna-Filho G, Costa EC. Controversies on Timing of Sex Assignment and Surgery in Individuals With Disorders of Sex Development: A Perspective. Front Pediatr 2019; 6:419. [PMID: 30687685 PMCID: PMC6335325 DOI: 10.3389/fped.2018.00419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022] Open
Abstract
Appropriate management of disorders of sex development (DSD) has been a matter of discussion since the first guidelines were published in the 1950s. In the last decade, with the advent of the 2006 consensus, the classical methods, especially regarding timing of surgery and sex of rearing, are being questioned. In our culture, parents of DSD newborns usually want their children to undergo genital surgery as soon as possible after sexual assignment, as surgery helps them to confirm the assigned sex. Developmental psychology theories back this hypothesis. They state that anatomic differences between sexes initiate the very important process of identification with the parent of the same sex. Sex-related endocrinological issues also demand early care. For example, using dihydrotestosterone cream to increase penile length or growth hormone treatment to improve final height require intervention at young ages to obtain better results. Although the timing of surgery remains controversial, recent evidence suggests that male reconstruction should be performed between 6 and 18 months of age. Feminizing surgery is still somewhat controversial. Most guidelines agree that severe virilization requires surgical intervention, while no consensus exists regarding mild cases. Our perspective is that precocious binary sex assignment and early surgery is a better management method. There is no strong evidence for delays and the consequences can be catastrophic in adulthood.
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Affiliation(s)
- Tatiana Prade Hemesath
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Psycology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Leila Cristina Pedroso de Paula
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Endocrinology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Clarissa Gutierrez Carvalho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Julio Cesar Loguercio Leite
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Medical Genetics Service, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Guilherme Guaragna-Filho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Eduardo Corrêa Costa
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 564] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, De Cuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfäfflin F, Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale A, Winter S, Whittle S, Wylie KR, Zucker K. Normas de Atención para la salud de personas trans y con variabilidad de género. INT J TRANSGENDERISM 2018. [DOI: 10.1080/15532739.2018.1503902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgend Health 2018; 3:57-70. [PMID: 29756044 PMCID: PMC5944396 DOI: 10.1089/trgh.2017.0053] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.
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Affiliation(s)
- William Byne
- Mental Illness Research Education and Clinical Center, James J Peters VA Medical Center, Bronx, New York
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai and Center for Transgender Medicine and Surgery at Mount Sinai, New York, New York
| | - Dan H. Karasic
- Department of Psychiatry, University of California, San Francisco, San Francisco, California
| | - Eli Coleman
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - A. Evan Eyler
- Departments of Psychiatry and Family Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Jeremy D. Kidd
- Department of Psychiatry, Division on Substance Use Disorders, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Heino F.L. Meyer-Bahlburg
- Division of Gender, Sexuality, and Health, New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Richard R. Pleak
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Hofstra North Shore-LIJ School of Medicine, Albert Einstein College of Medicine, Zucker Hillside Hospital, Ambulatory Care Pavilion, Glen Oaks, New York
| | - Jack Pula
- Department of Psychiatry, Division of Gender, Sexuality and Health, College of Physicians and Surgeons of Columbia University, New York, New York
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Viau-Colindres J, Axelrad M, Karaviti LP. Bringing Back the Term "Intersex". Pediatrics 2017; 140:peds.2017-0505. [PMID: 29070532 DOI: 10.1542/peds.2017-0505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Marni Axelrad
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Fleming L, Knafl K, Van Riper M. How the Child's Gender Matters for Families Having a Child With Congenital Adrenal Hyperplasia. JOURNAL OF FAMILY NURSING 2017; 23:516-533. [PMID: 29046104 DOI: 10.1177/1074840717735499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Children with congenital adrenal hyperplasia (CAH) are exposed to high levels of testosterone in utero often resulting in nontypical genitalia at birth for girls. The purpose of this analysis, which draws on data from a larger study, was to examine, based on the gender of the child, the family experiences of having a child with CAH. Sixteen parents were interviewed, and comparisons were made across all categories coded in the parents' interviews to examine similarities and differences in the experiences of families based on the child's gender. Families having a daughter with CAH experienced additional challenges when compared with families having a son. These include fear of stigmatization, challenging surgical decisions, and concerns regarding disclosure of the condition. Acknowledging this and creating support programs tailored for girls that address surgical procedures and complications resulting from being born with elevated testosterone are critical to promoting a healthy family and child response.
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Affiliation(s)
- Louise Fleming
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
| | - Kathleen Knafl
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
| | - Marcia Van Riper
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
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Sandberg DE, Gardner M, Callens N, Mazur T. Interdisciplinary care in disorders/differences of sex development (DSD): The psychosocial component of the DSD-Translational research network. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:279-292. [PMID: 28574671 DOI: 10.1002/ajmg.c.31561] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 01/28/2023]
Abstract
Scientific discovery and clinical management strategies for Disorders/Differences of Sex Development (DSD) have advanced in recent years. The 2006 Consensus Statement on Management of Intersex Disorders stated that a mental health component to care is integral to promote positive adaptation, yet the parameters of this element have not been described. The objective of this paper is threefold: to describe the psychosocial screening protocol adopted by the clinical centers of the DSD-Translational Research Network; to summarize psychosocial data collected at 1 of the 10 network sites; and to suggest how systematic behavioral health screenings can be employed to tailor care in DSD that results in better health and quality of life outcomes. Steps taken in developing the largely "noncategorical" screening protocol are described. These preliminary findings suggest that DSD, as one category of pediatric chronic conditions, is not associated with marked disturbances of psychosocial adaptation, either for the family or the child; however, screening frequently uncovered "risk factors" for individual families or patients that can potentially be addressed in the context of ongoing clinical care. Administration of the DSD-TRN psychosocial screening protocol was demonstrated to be feasible in the context of interdisciplinary team care and was acceptable to families on a longitudinal basis. The ultimate value of systematic screening will be demonstrated through a tailoring of psychosocial, medical and surgical services, based on this information that enhances the quality of patient and family-centered care and subsequent outcomes.
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Affiliation(s)
- David E Sandberg
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Melissa Gardner
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nina Callens
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.,Faculty of Arts and Philosophy, Department of Languages and Cultures, Center for Research on Culture and Gender, Ghent University, Ghent, Belgium
| | - Tom Mazur
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, New York
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Khattab A, Yau M, Qamar A, Gangishetti P, Barhen A, Al-Malki S, Mistry H, Anthony W, Toralles MB, New MI. Long term outcomes in 46, XX adult patients with congenital adrenal hyperplasia reared as males. J Steroid Biochem Mol Biol 2017; 165:12-17. [PMID: 27125449 DOI: 10.1016/j.jsbmb.2016.03.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/12/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023]
Abstract
Patients with Congenital Adrenal Hyperplasia (CAH) owing to 21-hydroxylase deficiency and whose karyotype is 46, XX are usually assigned to the female gender. Reported herein are the long term outcomes in three patients with CAH whose karyotype is 46, XX and who were reared as males. A retrospective review of three CAH patients with a 46, XX karyotype who were reared as males was conducted. Gender assignment, clinical and biochemical data, pre and post-genitoplasty genital examinations were reviewed. Gender identity was tested by an extensive questionnaire. Gender role, sexual preference, marital status and sexual satisfaction were evaluated by interview. The three patients were genotyped for the CYP21A2 gene confirming the diagnosis of CAH. Owing to genital virilization, cultural preferences for male gender and the lack of newborn screening programs the three patients reported herein were assigned to the male gender at birth before the diagnosis of CAH was established. In adulthood the patients remained significantly virilized. Thorough psychosexual assessments in adulthood revealed well established male gender identities compatible with their male gender assignments at birth. In all three patients, gender role and behavior were consistent with male gender identity including sexual intercourse with female partners. The three patients reported herein revealed that male gender assignment to CAH patients with a 46, XX karyotype may have a successful outcome providing there is strong parental support and expert endocrine care. No standard guidelines have been published for the gender assignment of CAH patients with a 46, XX karyotype and genital ambiguity. More studies concerning gender assignment in CAH patients with a 46, XX karyotype reared as males are needed.
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Affiliation(s)
- A Khattab
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M Yau
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Qamar
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - P Gangishetti
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Barhen
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - S Al-Malki
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - H Mistry
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - W Anthony
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M B Toralles
- Genetica Medica, Universidade Federal da Bahia, Salvador, State of Bahia, Brazil
| | - Maria I New
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
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16
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Lee PA, Nordenström A, Houk CP, Ahmed SF, Auchus R, Baratz A, Baratz Dalke K, Liao LM, Lin-Su K, Looijenga LHJ, Mazur T, Meyer-Bahlburg HFL, Mouriquand P, Quigley CA, Sandberg DE, Vilain E, Witchel S. Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care. Horm Res Paediatr 2016; 85:158-80. [PMID: 26820577 DOI: 10.1159/000442975] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022] Open
Abstract
The goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups. The goal of patient care is focused upon the best possible quality of life (QoL). The field of DSD is continuously developing. An update on the clinical evaluation of infants and older individuals with ambiguous genitalia including perceptions regarding male or female assignment is discussed. Topics include biochemical and genetic assessment, the risk of germ cell tumor development, approaches to psychosocial and psychosexual well-being and an update on support groups. Open and on-going communication with patients and parents must involve full disclosure, with the recognition that, while DSD conditions are life-long, enhancement of the best possible outcome improves QoL. The evolution of diagnosis and care continues, while it is still impossible to predict gender development in an individual case with certainty. Such decisions and decisions regarding surgery during infancy that alters external genital anatomy or removes germ cells continue to carry risk.
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Affiliation(s)
- Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pa., USA
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17
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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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18
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Olshan J, Eimicke T, Belfort E. Gender Incongruity in Children With and Without Disorders of Sexual Differentiation. Endocrinol Metab Clin North Am 2016; 45:463-82. [PMID: 27241976 DOI: 10.1016/j.ecl.2016.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Access to the Internet and recent major media coverage has contributed to an increased societal awareness of the variations of gender identity. There are two sets of clinical guidelines primarily used by practitioners who care for transgender adolescents and adults. Although these guidelines have been tremendously helpful for the management of transgender adolescents, those working in the field recognize the limitations of firm recommendations with a population that is so heterogeneous. This article will summarize current recommendations for the management of children and adolescents with gender incongruence and suggest ways in which we might vary from the current guidelines.
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Affiliation(s)
- Jerrold Olshan
- Division of Pediatric Endocrinology, The Barbara Bush Children's Hospital at Maine Medical Center, 887 Congress Street, Suite 100, Portland, ME 04102, USA; Division of Diabetes, The Barbara Bush Children's Hospital at Maine Medical Center, 887 Congress Street, Suite 100, Portland, ME 04102, USA.
| | - Toni Eimicke
- Division of Pediatric Endocrinology, The Barbara Bush Children's Hospital at Maine Medical Center, 887 Congress Street, Suite 100, Portland, ME 04102, USA
| | - Erin Belfort
- Child and Adolescent Psychiatry, Maine Medical Center, 66 Bramhall Street, Portland, ME 04102, USA; Tufts University School of Medicine, Boston, MA, USA
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19
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Mouriquand PDE, Gorduza DB, Gay CL, Meyer-Bahlburg HFL, Baker L, Baskin LS, Bouvattier C, Braga LH, Caldamone AC, Duranteau L, El Ghoneimi A, Hensle TW, Hoebeke P, Kaefer M, Kalfa N, Kolon TF, Manzoni G, Mure PY, Nordenskjöld A, Pippi Salle JL, Poppas DP, Ransley PG, Rink RC, Rodrigo R, Sann L, Schober J, Sibai H, Wisniewski A, Wolffenbuttel KP, Lee P. Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how? J Pediatr Urol 2016; 12:139-49. [PMID: 27132944 DOI: 10.1016/j.jpurol.2016.04.001] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/25/2016] [Accepted: 04/04/2016] [Indexed: 01/25/2023]
Abstract
Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.
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Affiliation(s)
- Pierre D E Mouriquand
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France.
| | - Daniela Brindusa Gorduza
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Claire-Lise Gay
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute, New York, NY, USA; College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Linda Baker
- Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laurence S Baskin
- Pediatric Urology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Claire Bouvattier
- Service d'Endocrinologie de l'enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France
| | - Luis H Braga
- Division of Urology, Department of Surgery, McMaster University, Toronto, Canada
| | - Anthony C Caldamone
- Pediatric Urology, Hasbro Children's Hospital, Providence, RI, USA; Surgery (Urology) and Pediatrics, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Lise Duranteau
- Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France; Adolescent Gynaecology, Hôpitaux Universitaires Paris Sud (Bicêtre), Paris, France
| | - Alaa El Ghoneimi
- Pediatric Surgery and Urology, University Hospital Robert Debré, APHP, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Terry W Hensle
- College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Piet Hoebeke
- Urology, Ghent University Hospital, Gent, Belgium
| | - Martin Kaefer
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicolas Kalfa
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Thomas F Kolon
- Pediatric Urology, Children's Hospital of Philadelphia, PA, USA; Perelman School of Medicine at University of Pennsylvania, PA, USA
| | - Gianantonio Manzoni
- Pediatric Urology, Fondazione IRCCS CaGranda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierre-Yves Mure
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - J L Pippi Salle
- Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Dix Phillip Poppas
- Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Philip G Ransley
- Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Richard C Rink
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Romao Rodrigo
- Department of Surgery, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Department of Urology, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Léon Sann
- Conseil d'éthique pédiatrique, Centre Hospitalo-Universitaire de Lyon, France
| | | | - Hisham Sibai
- Paediatric Surgery, University of Casablanca, Morocco
| | | | - Katja P Wolffenbuttel
- Department of Urology and Pediatric Urology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Peter Lee
- Penn State Hershey Pediatric Endocrinology, PA, USA
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20
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Meyer-Bahlburg HFL. Misrepresentation of evidence favoring early normalizing surgery for atypical sex anatomies: response to Baratz and Feder (2015). ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1765-1768. [PMID: 26246316 DOI: 10.1007/s10508-015-0602-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Heino F L Meyer-Bahlburg
- Gender, Sexuality, & Health, New York State Psychiatric Institute and Department of Psychiatry, College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA,
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21
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Lee PA, Wisniewski AB, Baskin L, Vogiatzi MG, Vilain E, Rosenthal SM, Houk C. Advances in diagnosis and care of persons with DSD over the last decade. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2014. [DOI: 10.1186/1687-9856-2014-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
PURPOSE OF REVIEW To describe the treatment of gender dysphoria in adolescents. RECENT FINDINGS Careful study and evaluation of children with persistent severe gender dysphoria has led to the recommendation that puberty be suppressed at Tanner Stage II. If the dysphoria persists until age 16, treatment with sex steroids of the appropriate gender may begin at age 16 and be followed by gender-appropriate surgery. SUMMARY Protocols and results of treatment of early adolescents have demonstrated that the harmful effects of persistent gender dysphoria can be prevented. Pubertal suppression in early puberty not only prevents the severe distress, but also allows healthy adolescent development living in the appropriate gender.
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Affiliation(s)
- Wylie C Hembree
- Columbia University College of Physicians and Surgeons, New York, New York, USA
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23
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Tamar-Mattis A, Baratz A, Baratz Dalke K, Karkazis K. Emotionally and cognitively informed consent for clinical care for differences of sex development. PSYCHOLOGY & SEXUALITY 2013. [DOI: 10.1080/19419899.2013.831215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
This article summarizes for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development (DSD) or with non-DSD transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA.
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25
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Wisniewski AB. Gender Development in 46,XY DSD: Influences of Chromosomes, Hormones, and Interactions with Parents and Healthcare Professionals. SCIENTIFICA 2012; 2012:834967. [PMID: 24278745 PMCID: PMC3820494 DOI: 10.6064/2012/834967] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/18/2012] [Indexed: 06/02/2023]
Abstract
Variables that impact gender development in humans are difficult to evaluate. This difficulty exists because it is not usually possible to tease apart biological influences on gender from social variables. People with disorders of sex development, or DSD, provide important opportunities to study gender within individuals for whom biologic components of sex can be discordant with social components of gender. While most studies of gender development in people with 46,XY DSD have historically emphasized the importance of genes and hormones on gender identity and gender role, more recent evidence for a significant role for socialization exists and is considered here. For example, the influence of parents' perceptions of, and reactions to, DSD are considered. Additionally, the impact of treatments for DSD such as receiving gonadal surgeries or genitoplasty to reduce genital ambiguity on the psychological development of people with 46,XY DSD is presented. Finally, the role of multi-disciplinary care including access to peer support for advancing medical, surgical and psychosexual outcomes of children and adults with 46,XY DSD, regardless of sex of rearing, is discussed.
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Affiliation(s)
- Amy B Wisniewski
- Department of Urology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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