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Ussher JM, Carpenter M, Power R, Ryan S, Allison K, Hart B, Hawkey A, Perz J. "I've had constant fears that I'll get cancer": the construction and experience of medical intervention on intersex bodies to reduce cancer risk. Int J Qual Stud Health Well-being 2024; 19:2356924. [PMID: 38796859 PMCID: PMC11134048 DOI: 10.1080/17482631.2024.2356924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 05/14/2024] [Indexed: 05/29/2024] Open
Abstract
PURPOSE This paper examines the subjective experience of medical interventions on intersex bodies to reduce cancer risk. METHODS Twenty-five individuals with intersex variations took part in semi-structured interviews, analysed through thematic discourse analysis. RESULTS Intersex bodies were positioned as inherently sick and in need of modification, with cancer risk legitimating surgical and hormonal intervention. This resulted in embodied shame, with negative impacts on fertility and sexual wellbeing. However, many participants resisted discourses of bio-pathologisation and embraced intersex status. Some medical interventions, such as HRT, were perceived to have increased the risk of cancer. Absence of informed consent, and lack of information about intersex status and the consequences of medical intervention, was positioned as a human rights violation. This was compounded by ongoing medical mismanagement, including health care professional lack of understanding of intersex variations, and the objectification or stigmatization of intersex people within healthcare. The consequence was non-disclosure of intersex status in health contexts and lack of trust in health care professionals. CONCLUSIONS The legitimacy of poorly-evidenced cancer risk discourses to justify medical intervention on intersex bodies needs to be challenged. Healthcare practitioners need to be provided with education and training about cultural safety practices for working with intersex people.
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Affiliation(s)
- Jane M. Ussher
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Morgan Carpenter
- Intersex Human Rights Australia, Sydney, Australia
- Faculty of Medicine and Health, Sydney Health Ethics, Sydney, Australia
| | - Rosalie Power
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Samantha Ryan
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Kimberley Allison
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Bonnie Hart
- School of Psychology and Counselling, Faculty of Health, Queensland University of Technology, Kelvin Grove, Brisbane, Australia
| | - Alexandra Hawkey
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Janette Perz
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
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2
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Khorashad BS, Gardner M, Lee PA, Kogan BA, Sandberg DE. Recommendations for 46,XY Disorders/Differences of Sex Development Across Two Decades: Insights from North American Pediatric Endocrinologists and Urologists. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2939-2956. [PMID: 39039338 PMCID: PMC11335971 DOI: 10.1007/s10508-024-02942-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/10/2024] [Accepted: 06/13/2024] [Indexed: 07/24/2024]
Abstract
Clinical decision-making for individuals with 46,XY disorders/differences of sex development (DSD) remains unsettled and controversial. The North American DSD Clinician Survey examines the recommendations of a large group of clinical specialists over the last two decades. Active members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology were invited to respond to a web-based survey at three different timepoints: 2003-2004 (T1), 2010-2011 (T2), and 2019-2020 (T3). Data from 429 participants in T1, 435 in T2, and 264 in T3 were included in this study. The participants were presented with three XY newborn clinical case scenarios-micropenis, partial androgen insensitivity syndrome, and iatrogenic penile ablation-and asked for clinical management recommendations. The main outcomes assessed included the recommended gender of rearing, surgical decision-maker (parent or patient), timing of genital surgery, and age at which to disclose medical details and surgical history to the patient. For all scenarios, the overwhelming majority recommended rearing as male, including a significant increase across timepoints in those recommending a male gender of rearing for the infant with penile ablation. The proportions recommending female gender of rearing declined significantly across timepoints. In general, most recommended parents (in consultation with the physician) serve as surgical decision-makers, but these proportions declined significantly across timepoints. Recommendations on the timing of surgery varied based on the patient's gender and type of surgery. There has been a shift in recommendations away from the "optimal gender policy" regarding gender of rearing and surgical interventions for patients with XY DSD.
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Affiliation(s)
- Behzad Sorouri Khorashad
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA
| | - Melissa Gardner
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA.
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
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3
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Crocetti D, Berry A, Monro S. Navigating the complexities of adult healthcare for individuals with variations of sex characteristics: from paediatric emergencies to a sense of abandonment. CULTURE, HEALTH & SEXUALITY 2024; 26:332-345. [PMID: 37199261 DOI: 10.1080/13691058.2023.2208194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
Intersex people and those with variations of sex characteristics face significant health and social issues. This paper analyses the complexities of adult healthcare for this diverse population, including the root causes of deficiencies in care provision. Many minors with variations of sex characteristics are subjected to irreversible, non-consensual medical interventions, which can have negative effects on their health and wellbeing as adults. This 'emergency' approach to intersex paediatric healthcare has been challenged since the 1990s, but there is still a lack of understanding about how the paradigm affects adult care. This paper aims to raise awareness of the health challenges faced by adults with variations of sex characteristics. It identifies themes related to the challenges associated with accessing appropriate adult care, including the repercussions of childhood treatment, the lack of transitional services and psychological support, the limited general medical knowledge about variations of sex characteristics, and the reluctance to access services due to fear of stigma or past medical trauma. The paper indicates the need for more attention to intersex people's health needs as adults, moving away from attempts to 'fix' them as minors towards approaches which consider and provide for their diverse healthcare needs in a broader temporal context.
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Affiliation(s)
- Daniela Crocetti
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
- subsequently Independent Researcher, Intersexesiste NGO, Bologna, Italy
| | - Adeline Berry
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Surya Monro
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
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4
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Berry AW, Monro S. Ageing in obscurity: a critical literature review regarding older intersex people. Sex Reprod Health Matters 2022; 30:2136027. [DOI: 10.1080/26410397.2022.2136027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeline W. Berry
- Marie Curie Research Fellow, University of Huddersfield, Huddersfield, UK. Correspondence:
| | - Surya Monro
- Professor of Sociology and Social Policy, University of Huddersfield, Huddersfield, UK
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5
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Earp BD. Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm. FRONTIERS IN HUMAN DYNAMICS 2022. [DOI: 10.3389/fhumd.2022.778592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.
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Meoded Danon L. Temporal sociomedical approaches to intersex* bodies. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:28. [PMID: 35674937 DOI: 10.1007/s40656-022-00511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
The history of the field of intersex bodies/bodies with variations of sex development (VSD) reflects the ongoing tension between sociomedical attempts to control uncertainty and reduce the duration of corporeal uncertainty by means of early diagnosis and treatment, and the embodied subjects who resist or challenge these attempts, which ultimately increase uncertainty. Based on various qualitative studies in the field of intersex, this article describes three temporal sociomedical approaches that have evolved over the last decade and aims to address the uncertainty surrounding intersex/VSD bodies. These approaches are (1) the corrective-concealing approach, which includes early surgeries and hormone therapies intended to "correct" intersex conditions and the deliberate concealment of the ambiguity and uncertainty associated with intersex conditions; (2) the preventive approach, which involves early genetic diagnostic methods aimed at regulating or preventing the recurrence of hereditary conditions under the umbrella of VSD; and (3) the wait-and-see approach, which perceives intersex bodies as natural variations and encourages parents to take time, wait, and give their children the right to bodily autonomy. A comparison of these approaches from biopolitical, phenomenological, and pragmatic perspectives reveals that time is an essential social agent in addressing and controlling uncertainty, a gatekeeper of social norms and social and physical orders, and, on the other hand, a sociopolitical agent that enables creative social change.
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Suorsa-Johnson KI, Gardner MD, Baskin A, Gruppen LD, Rose A, Rutter MM, Schafer-Kalkhoff T, Stacey D, van Leeuwen KD, Weidler EM, Sandberg DE. Defining successful outcomes and preferences for clinical management in differences/disorders of sex development: Protocol overview and a qualitative phenomenological study of stakeholders' perspectives. J Pediatr Urol 2022; 18:36.e1-36.e17. [PMID: 34876378 PMCID: PMC8983568 DOI: 10.1016/j.jpurol.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/25/2021] [Accepted: 10/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Utilizing a qualitative phenomenological design, the Defining Successful Outcomes and Trade-offs study examined stakeholder perspectives regarding optimal healthcare delivery and outcomes for individuals with a difference/disorder of sex development (DSD). OBJECTIVE We describe study methods and provide an overview of themes and subthemes. STUDY DESIGN Interviews were conducted with individuals with a DSD (n = 24), parents of those with a DSD (n = 19), healthcare providers (n = 37), and others (n = 30). Primary questions regarding clinical management of patients with DSD were: "What is a successful outcome?" and "How do you achieve it?" RESULTS Themes included: understanding of DSD diagnosis and self-efficacy in management is necessary but complex; patient and family psychological well-being; support from others versus being stigmatized; affected person experiences physical health and accepts the implications of their condition; complexities in DSD decision making, roles and expectations; and knowledgeable providers and multidisciplinary teams are essential, notwithstanding persisting barriers. Participants recognized competing values potentially forcing trade-offs in decision making. DISCUSSION Recognition of diverse and sometimes conflicting perspectives regarding optimal pathways of care and outcomes - both within and among those with DSD and their providers -promises to enhance shared decision making. CONCLUSION Diverse perspectives and perceptions of trade-offs associated with DSD healthcare emphasize the need to tailor care for patients and families.
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Affiliation(s)
- Kristina I Suorsa-Johnson
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Melissa D Gardner
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Alison Baskin
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA
| | - Larry D Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - Angela Rose
- Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Meilan M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA; Accord Alliance, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Dawn Stacey
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; School of Nursing, University of Ottawa, Ottawa, Canada
| | - Kathleen D van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - David E Sandberg
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA; Accord Alliance, USA.
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8
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Andrade G, Redondo MC. The need for "gentle medicine" in a post Covid-19 world. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:475-486. [PMID: 34415502 PMCID: PMC8377702 DOI: 10.1007/s11019-021-10046-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 05/24/2023]
Abstract
As it has historically been the case with many pandemics, the Covid-19 experience will induce many philosophers to reconsider the value of medical practice. This should be a good opportunity to critically scrutinize the way medical research and medical interventions are carried out. For much of its history, medicine has been very inefficient. But, even in its contemporary forms, a review of common protocols in medical research and medical interventions reveal many shortcomings, especially related to methodological flaws, and more importantly, conflicts of interests due to profit incentives. In the face of these problems, we propose a program of "gentle medicine". This term, originally formulated by philosopher Jacob Stegenga, describes a form of medicine in which physicians intervene less than they currently do. As part of this general program, we advance a series of reform recommendations that could be enacted both by medical staff in their everyday practice, but also by public health officials and policymakers.
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9
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Parental decisional regret after surgical treatment in young boys born with hypospadias. J Pediatr Urol 2021; 17:691.e1-691.e7. [PMID: 34305009 DOI: 10.1016/j.jpurol.2021.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias. METHODS Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret. RESULTS Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret. CONCLUSIONS A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.
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10
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Vora KA, Hanna CA, Neville KA, Bergman PB, Grover SR, O'Connell MA, Srinivasan S. Role of cross-campus multidisciplinary team meetings in decision-making for children and adolescents with differences of sex development/intersex. J Paediatr Child Health 2021; 57:1402-1407. [PMID: 33928709 DOI: 10.1111/jpc.15474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/21/2020] [Accepted: 03/26/2021] [Indexed: 11/29/2022]
Abstract
AIM Management of children with differences/disorders of sex development (DSD) is complex with limited evidence to guide clinical decisions. Regular multidisciplinary team meetings were set up in Sydney and Melbourne paediatric hospitals to enable systematic peer review of complex decision-making. We aim to describe the workload and role of these meetings. METHODS The multidisciplinary team forum includes invited representatives from endocrinology, urology, gynaecology, genetics, psychology, social work, clinical ethics, laboratory and hospital executive and meetings occur 1-3 times monthly. Descriptive data were collected from de-identified meeting referrals and minutes between August 2012 to August 2018 (Sydney) and January 2014 to August 2018 (Melbourne). RESULTS A total of 192 referrals (142 new and 50 follow-ups) aged 1 week to 17 years were discussed across the two sites. 46, XY DSD (n = 81) was the most common sub-classification. Consideration of surgical options and optimal management of gonads with malignant potential were amongst the common reasons for referral to the multidisciplinary team meetings. Surgical interventions were considered but not recommended after review for 38 of 154 (24.7%) procedures. Gonad retention to allow potential functional benefit was recommended in 15/46 (32.6%) referrals. Evidence of premalignant or malignant changes was found in 20/57 (35%) gonads removed, with dysgenetic features and atrophy/streak features in 6 (10.5%) and 27 (47.4%) gonads respectively. CONCLUSION Formal DSD multidisciplinary team meetings provide a framework and opportunity for multi and interdisciplinary discussions amongst representatives from several specialities to help make complex decision-making.
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Affiliation(s)
- Komal A Vora
- Department of Paediatric Endocrinology, John Hunter Children's Hospital, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chloe A Hanna
- Department of Gynaecology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Reproductive development, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, Sydney, NSW, Australia.,School of Women and Children's Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Philip B Bergman
- Department of Paediatric Endocrinology & Diabetes, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Department of Gynaecology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Reproductive development, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Michele A O'Connell
- Reproductive development, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Children's Hospital Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
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11
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Nelwan D, Mount C, Morganstern B, Chan JT. Infant With Severe Penoscrotal Hypospadias: A Complex Case of Genital Ambiguity and Mistaken Identity. Cureus 2021; 13:e15191. [PMID: 34178511 PMCID: PMC8218553 DOI: 10.7759/cureus.15191] [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: 11/05/2022] Open
Abstract
Individuals with an incongruence of their chromosomal sex and genital appearance are classified as having a disorder of sexual development (DSD), and they often present with ambiguous genitalia. The diagnosis and management of DSD patients are usually challenging and require a multidisciplinary approach. Gender assignment should not be based solely on physical exam and imaging but also on the genotype and hormonal function of the gonads. We present an infant born with ambiguous genitalia; the parents were told they were having a male infant during the prenatal ultrasound but at birth, the infant was found to have female-appearing external genitalia with no palpable gonads. MRI of the abdomen was inconclusive, but further workup, including karyotype, hormonal function, and intraoperative evaluation, was consistent with a male infant. He was, therefore, subsequently assigned to the male sex.
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Affiliation(s)
- David Nelwan
- Urology, Medical College of Georgia at Augusta University, Augusta, USA
| | - Conner Mount
- Urology, Medical College of Georgia at Augusta University, Augusta, USA
| | | | - Jacqueline T Chan
- Pediatric Endocrinology, Medical College of Georgia at Augusta University, Georgia, USA
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12
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Bennecke E, Bernstein S, Lee P, van de Grift TC, Nordenskjöld A, Rapp M, Simmonds M, Streuli JC, Thyen U, Wiesemann C. Early Genital Surgery in Disorders/Differences of Sex Development: Patients' Perspectives. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:913-923. [PMID: 33712989 PMCID: PMC8035116 DOI: 10.1007/s10508-021-01953-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 05/04/2023]
Abstract
Controversy continues over a proposed moratorium on elective genital surgery in childhood for disorders/differences of sex development (DSD). Empirical evidence on patient preference is needed to inform decision-making. We conducted a multicentre survey by cross-sectional questionnaire in 14 specialized clinics in six European countries. The sample comprised 459 individuals (≥ 16 years) with a DSD diagnosis, including individuals with congenital adrenal hyperplasia (CAH) (n = 192), XY DSD with prenatal androgen effect (A) (n = 150), and without (nA) (n = 117). Main outcome measures were level of agreement with given statements regarding genital surgery, including clitoris reduction, vaginoplasty, and hypospadias repair. A total of 66% of individuals with CAH and 60% of those with XY DSD-A thought that infancy or childhood were the appropriate age for genital surgery. Females with XY DSD were divided on this issue and tended to prefer vaginoplasty at a later age (XY DSD-A 39%, XY DSD-nA 32%). A total of 47% of males preferred early hypospadias surgery. Only 12% (CAH), 11% (XY DSD-A), and 21% (XY DSD-nA) thought they would have been better off without any surgery in childhood or adolescence. Individuals who had early genital surgery were more likely to approve of it. Outcome data failed to support a general moratorium on early elective genital surgery. Participant perspectives varied considerably by diagnostic category, gender, history of surgery, and contact with support groups. Case-by-case decision-making is better suited to grasping the ethical complexity of the issues at stake.Trial registration: German Clinical Trials Register DRKS00006072.
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Affiliation(s)
- Elena Bennecke
- Department of Paediatric Endocrinology and Diabetology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Sozialpädiatrisches Zentrum, Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stephanie Bernstein
- Department of Paediatrics, Göttingen University Medical Center, Göttingen, Germany
| | - Peter Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (VUmc), Amsterdam, The Netherlands
- Department of Medical Psychology and Sexology, Amsterdam University Medical Center, Amsterdam (VUmc), The Netherlands
| | - Agneta Nordenskjöld
- Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, and Center of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marion Rapp
- Klinik für Kinder- und Jugendmedizin, Universität zu Lubeck, Lubeck, Germany
| | | | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin, Universität zu Lubeck, Lubeck, Germany
| | - Claudia Wiesemann
- Department of Medical Ethics and History of Medicine, Göttingen University Medical Center, Humboldtallee 36, 37073, Göttingen, Germany.
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13
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Monro S, Carpenter M, Crocetti D, Davis G, Garland F, Griffiths D, Hegarty P, Travis M, Cabral Grinspan M, Aggleton P. Intersex: cultural and social perspectives. CULTURE, HEALTH & SEXUALITY 2021; 23:431-440. [PMID: 33783329 DOI: 10.1080/13691058.2021.1899529] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Peter Aggleton
- The Australian National University, Australia & The Centre for Gender and Global Health, UCL, UK
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14
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van de Grift TC. A textbook example of bias in Disorders/Differences of Sex Development (DSD) outcome research. A commentary to: "Congenital adrenal hyperplasia: Does repair after two years of age have a worse outcome?". J Pediatr Urol 2020; 16:742-743. [PMID: 32948451 DOI: 10.1016/j.jpurol.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Location VUmc Boelelaan 1117 (ZH 4D 120), Amsterdam 1081 HV, the Netherlands; Medical Psychology and Sexology, Amsterdam UMC, Location VUmc Boelelaan 1117 (ZH 4D 120), Amsterdam 1081 HV, the Netherlands.
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Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent. Sex Med 2020; 8:472-489. [PMID: 32507554 PMCID: PMC7471094 DOI: 10.1016/j.esxm.2020.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion. AIM The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions. METHODS A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis. MAIN OUTCOME MEASURE Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making. RESULTS The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence. CONCLUSION The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.
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Affiliation(s)
- Ute Lampalzer
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katinka Schweizer
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Kudela G, Gawlik A, Koszutski T. Early Feminizing Genitoplasty in Girls with Congenital Adrenal Hyperplasia (CAH)-Analysis of Unified Surgical Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113852. [PMID: 32485822 PMCID: PMC7312042 DOI: 10.3390/ijerph17113852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
AIM To analyze a single-centre experience in feminizing genitoplasty in virilized girls with congenital adrenal hyperplasia (CAH). METHODS Review of medical records of all 46, XX CAH patients undergoing single stage feminizing genitoplasty between 2003 and 2018 was performed. RESULTS A total of 31 girls aged from 4 months to 10 years were included in the study. The majority (n = 26/31, 84%) were operated before 2 years of age (median 8 months). External virilization was rated as Prader 3 (n = 7/31), Prader 4 (n = 21/31) and Prader 5 (n = 3/31). The urethrovaginal confluence location was low in 19 and high in 12 girls with a percentage distribution similar in Prader 4 and 5 (p > 0.05) but significantly different in Prader 3 (p = 0.017). The follow-up ranged from 12 months to 15 years. All parents assessed the cosmetic result as satisfactory. Perioperative complications occurred in two patients and included rectal injury (n = 1/31) and prolonged bleeding (n = 1/31). Three patients developed late complications including labial atheromas (n = 2/31) and vaginal stricture requiring surgical dilatation (n = 1/31). Low confluence did not decrease the risk of complications. CONCLUSIONS Early feminizing genitoplasty in girls with congenital adrenal hyperplasia, irrespective of virilization severity, gives satisfactory cosmetic results and is characterized by low and acceptable surgical risk. Nevertheless, the most important determinant of the effectiveness of such management would be future patients' satisfaction.
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Affiliation(s)
- Grzegorz Kudela
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
- Correspondence: ; Tel.: +48-501 460 285
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Tomasz Koszutski
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
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17
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Şentürk Pilan B, Özbaran B, Çelik D, Özcan T, Özen S, Gökşen D, Ulman İ, Avanoğlu A, Tiryaki S, Onay H, Çoğulu Ö, Özkınay F, Darcan Ş. Psychiatric view for disorders of sex development: a 12-year experience of a multidisciplinary team in a university hospital. J Pediatr Endocrinol Metab 2020; 33:605-611. [PMID: 32238607 DOI: 10.1515/jpem-2019-0513] [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: 10/30/2019] [Accepted: 02/24/2020] [Indexed: 11/15/2022]
Abstract
Background Psychiatric consultation is important in the follow-up of disorders of sex development (DSD) patients. In this study, we aimed to present the 12-year psychiatric follow-up data of the patients who were referred by Ege University Medical Faculty DSD Multidisciplinary Team and followed up in Child and Adolescent Psychiatry. Methods Psychiatric data of 118 patients, who were followed by the DSD multidisciplinary team between 2007 and 2019, were reviewed retrospectively. The psychiatric diagnoses of the patients were evaluated according to semi-structured interview form Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Turkish Version. Results The mean age of the 118 cases was 13.21 years (±7.18). Endocrine diagnoses of the cases were 46 XX DSD in 35 (29.6%), 46 XY DSD in 81 (68.7%), and chromosome disorders in 2 (1.7%). There was at least psychiatric diagnosis in 36 (30.5%) cases. The most common psychiatric diagnosis was attention deficit and hyperactivity disorder (ADHD) (n = 18, 15.3%). ADHD was most common in congenital adrenal hyperplasia (n = 4, 22.4%) and androgen synthesis defects (ASD) (n = 4, 22.4%); depression was most common in complete gonadal dysgenesis and ASD (n = 3, 23.1%); and mental retardation was most common in ASD (n = 3, 37.5%). Conclusions In order to provide a healthy perspective for cases with DSD, it is important to make a psychiatric evaluation and to share observations and clinical findings in regular team meetings.
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Affiliation(s)
- Birsen Şentürk Pilan
- Ege University Faculty of Medicine, Child and Adolescent Psychiatry, İzmir, Turkey
| | - Burcu Özbaran
- Ege University Faculty of Medicine, Child and Adolescent Psychiatry, İzmir, Turkey
| | - Didem Çelik
- Ege University Faculty of Medicine, Child and Adolescent Psychiatry, İzmir, Turkey
| | - Tuğçe Özcan
- Ege University Faculty of Medicine, Child and Adolescent Psychiatry, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - İbrahim Ulman
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Ali Avanoğlu
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Sibel Tiryaki
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Hüseyin Onay
- Ege University Faculty of Medicine, Medical Genetics, İzmir, Turkey
| | - Özgür Çoğulu
- Ege University Faculty of Medicine, Medical Genetics, İzmir, Turkey
| | - Ferda Özkınay
- Ege University Faculty of Medicine, Medical Genetics, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
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Lee PA, Fuqua JS, Houk CP, Kogan BA, Mazur T, Caldamone A. Individualized care for patients with intersex (disorders/differences of sex development): part I. J Pediatr Urol 2020; 16:230-237. [PMID: 32249189 DOI: 10.1016/j.jpurol.2020.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022]
Abstract
The care of individuals with disorders/differences of sex development aims to enable affected individuals and their families to have the best quality of life, particularly those born with severe genital ambiguity. Two of the biggest concerns for parents and health professionals are: (1) making a gender assignment and (2) the decisions of whether or not surgery is indicated, and if so, when is best for the patient and parents. These decisions, which can be overwhelming to families, are almost always made in the face of uncertainties. Such decisions must involve the parents, include multidisciplinary contributions, have an underlying principle of full disclosure, and respect familial, philosophical, and cultural values. Assignment as male or female is made with the realization that gender identity cannot be predicted with certainty. Because of the variability among those with the same diagnosis and complexity of phenotype-genotype correlation, the use of algorithms is inappropriate. The goal of this article is to emphasize the need for individualized care to make the best possible decisions for each patient's unique situation.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Hershey, PA 17033, USA.
| | - John S Fuqua
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | | | | | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, John R. Oishei Children's Hospital, Buffalo, NY 14222, USA.
| | - Anthony Caldamone
- Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI 02903, USA.
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19
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Ethische Aspekte der Versorgung von Kindern mit „disorders/differences of sex development“. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0716-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Lundberg T, Dønåsen I, Hegarty P, Roen K. Moving intersex/DSD rights and care forward: Lay understandings of common dilemmas. JOURNAL OF SOCIAL AND POLITICAL PSYCHOLOGY 2019. [DOI: 10.5964/jspp.v7i1.1012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
When sex characteristics develop in ways that do not conform to binary models, dilemmas arise regarding how to understand the situation and what terminology to use to describe it. While current medical nomenclature suggests that it should be understood as a disorder of sex development (DSD) prompting medical responses, many describe intersex as a human variation in sexed embodiment that should be protected under discrimination laws. These opposing perspectives suggest different principles to employ in responding to dilemmas about gender assignment, early genital surgery and full disclosure of medical information. In this discursive psychological study, we explore how lay people, without prior knowledge or experience of intersex/DSD, make sense of these dilemmas and the underpinning discourses giving rise to how they talk about these situations. By using the discursive framework of ideological dilemmas, we analyse how people make sense of sex and gender (as binary or non-binary), how they deal with difference (as problematic or not), and how they understand who is in a position to make decisions in such situations. We conclude that engaging with dilemmas in-depth is more constructive than favouring one principle over others in moving social science research, reflexive clinical practice, and wider political debates on intersex/DSD forward.
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21
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Szymanski KM, Whittam B, Monahan PO, Kaefer M, Frady H, Cain MP, Rink RC. Validation and Preliminary Results of the Parental Assessment of Children's External Genitalia Scale for Females (PACE-F) for Girls With Congenital Adrenal Hyperplasia. Urology 2019; 130:132-137. [PMID: 31071351 DOI: 10.1016/j.urology.2019.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/23/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To validate a parental assessment of children's external genitalia scale for females (PACE-F) for girls with congenital adrenal hyperplasia (CAH) by adapting the validated adult female genital self-image scale. METHODS PACE-F was administered to parents of girls (Tanner 1, 2 months-12 years) with and without CAH. Final questions were determined by clinical relevance and psychometric properties (scores: 0-100). A reference range was established using 95% confidence interval among controls. Age-matched controls were compared to girls with CAH (1) <4 years old before and after female genital reconstruction surgery (FGRS), and (2) 4-12-year olds after FGRS. Nonparametric statistics were used. RESULTS Participants included 56 parents of 41 girls with CAH (median 3.9 years old, 97.6% FGRS) and 139 parents of 130 girls without CAH. Face and content validity was established by families, experts, and factor analysis. Internal consistency was high (Cronbach's alpha: 0.83). Population reference score range was 66.7-100. Ten consecutive girls had pre- and post-FGRS PACE-F scores. All scores improved at 4 months after surgery and all preoperative scores were below reference range and lower than controls (P = .0001). All postoperative scores were within reference range, no different from controls (P = .18). Scores for girls with CAH after FGRS aged 4-12 years were no different from controls (100.0 vs 88.9, P = .77) and 90.0% were in reference range, as expected (P = .99). CONCLUSION We present a validated instrument for parental assessment of genital appearance in girls with CAH. We demonstrate improved parent-reported appearance after FGRS, with scores similar to age-matched controls.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine and School of Public Health, Indianapolis, IN
| | - Martin Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Heather Frady
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Mark P Cain
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
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22
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Harris RM, Chan YM. Ethical issues with early genitoplasty in children with disorders of sex development. Curr Opin Endocrinol Diabetes Obes 2019; 26:49-53. [PMID: 30507698 DOI: 10.1097/med.0000000000000460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Genitoplasty in children with disorders of sex development (DSD) is an ethically complex issue. From a surgical perspective, genitoplasty in early childhood is preferred because it is felt to be associated with improved tissue healing, decreased risk of complications, and reduced psychological impact of genital surgery. However, advocacy groups and recent ethics literature have argued for deferring genitoplasty until a child reaches decisional maturity. This article reviews these arguments using an ethical framework and discusses the application and challenges of recent disorders of sex development research. RECENT FINDINGS Recent ethics literature and advocacy groups have argued for deferring genitoplasty until a child reaches decisional maturity. As a counterpoint, urological societies have published arguments supporting the practice of early genitoplasty. Data from DSD research lends some guidance but also has a wide range of outcomes, which makes generalizability difficult. A retrospective, multicenter study of 21 individuals with congenital adrenal hyperplasia who underwent feminizing surgery showed no difference between cases and controls in social functioning, parent-child relationships, or sexual fulfillment. Ninety percent of patients thought genitoplasty should occur within the first year of life. In a study of 52 patients with 46,XY and 46,XX DSDs who underwent masculinizing genitoplasty, 57% thought their physical appearance was 'fair' or 'poor,' and problems with sexual function, urinary incontinence, and short penile length were common. SUMMARY Early genitoplasty in children with DSDs is ethically complex, and discordant results in DSD research makes generalizability difficult. There is unlikely to be a universal solution to the issue of early genitoplasty in children with DSDs; families must be supported while they weigh both parental decision-making and the objective of ensuring an open future for their child.
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Affiliation(s)
- Rebecca M Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
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23
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Affiliation(s)
- Surya Monro
- Centre for Citizenship, Conflict, Identity and Diversity, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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24
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Cresti M, Nave E, Lala R. Intersexual Births: The Epistemology of Sex and Ethics of Sex Assignment. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:557-568. [PMID: 30367362 DOI: 10.1007/s11673-018-9880-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
This article aims to analyse a possible manner of approaching the birth of intersexual children. We start out by summing up what intersexuality is and how it is faced in the dominant clinical practice (the "treatment paradigm"). We then argue against this paradigm, in favour of a postponement of genital surgery. In the second part of this paper, we take into consideration the general question of whether only two existing sexes are to be recognized, arguing in favour of an expansion of sex categories. In the third part, we illustrate the reasons supporting provisional sex attribution: the child's best interest and respect for their developing moral autonomy. This position aims to increase the child's well-being and self-determination, limiting parents' freedom to take decisions on behalf of others, in particular, those decisions concerning basic aspects of their children's personal identity.
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Affiliation(s)
- Matteo Cresti
- Department of Philosophy and Education Science, University of Turin, Via Sant'Ottavio 20, 10124, Turin, Italy.
| | - Elena Nave
- Pediatric Pneumology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, Piazza Polonia 94, 10126, Turin, Italy
| | - Roberto Lala
- Pediatric Endocrinology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, Piazza Polonia 94, 10126, Turin, Italy
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25
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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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26
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Szymanski KM, Whittam B, Kaefer M, Frady H, Cain MP, Rink RC. What about my daughter's future? Parental concerns when considering female genital restoration surgery in girls with congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:417.e1-417.e5. [PMID: 30126743 DOI: 10.1016/j.jpurol.2018.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/12/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE The parental decision-making process regarding female genital restoration surgery (FGRS) for girls with congenital adrenal hyperplasia (CAH) is controversial and poorly understood. The aim of the study aim was to evaluate parental concerns related to their child's future and parental plans about disclosure prior to FGRS. MATERIALS AND METHODS The authors performed an online survey of consecutive parents presenting at a tertiary referral center for consultation regarding FGRS for their daughter with CAH before 3 years of age (2016-2018). Twenty issues initially identified by three families and six clinicians were rated on a 6-point Likert scale of importance ('not at all' to 'extremely'). RESULTS Sixteen consecutive families participated (Prader 3/4/5: 43.8%/43.8%/12.5%). Fourteen girls (87.5%) subsequently underwent FGRS at a median age of 8 months. Most issues (19/20, 95.0%) were ranked 'quite a bit' to 'extremely' important (Table). Top issues were not surgical: Normal physical/mental development, adrenal crisis and side-effects of medications. Surgery-related and self-image concerns followed in importance. Least prioritized issues were multiple genital exams ('quite a bit' important) and the child not being involved in the decision to proceed with FGRS ('somewhat' important). On average, no issues were considered 'not at all' or 'a little' important. Disclosure of FGRS to their daughter was the 15th prioritized issues. Almost all families (93.8%, 1 unsure) planned to disclose the surgery to their daughter, although many were unsure when and how to do it (33.3% and 37.5%, respectively). COMMENT Initial efforts to understand the complex process of parental decision-making regarding FGRS in the context of CAH, a complex, multifactorial disease, are presented. Parents of infant girls with CAH simultaneously weigh multiple life-threatening concerns with a decision about FGRS. While issues of genital ambiguity and surgery are important, they are not overriding concerns for parents of girls with CAH. Parents report significant uncertainty about appropriate timing and approach to disclosing FGRS to their daughters. Unfortunately, best practice guidelines for this process are lacking. The findings are not based on actual history of disclosure but on parents' anticipated behavior. Further data are need from parents, children, and women with CAH about successful disclosure. Being a single-center series, these data may not correspond to the wider CAH community. CONCLUSIONS Parental decision-making regarding FGRS is multifactorial. Even when considering FGRS, parents' largest concerns remain focused on the life-threatening and developmental effects of CAH and side-effects of its medical treatment. The disclosure process deserves further attention.
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Affiliation(s)
- K M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA.
| | - B Whittam
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - M Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - H Frady
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - M P Cain
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - R C Rink
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
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27
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Sanders C, Hall J, Sanders C, Dessens A, Bryce J, Callens N, Cools M, Kourime M, Kyriakou A, Springer A, Audi L, Balsamo A, Iotova V, Mladenov V, Krawczynski M, Nordenskjöld A, Rozas M, Claahsen-van der Grinten H, Hiort O, Riedl S, Ahmed SF. Involving Individuals with Disorders of Sex Development and Their Parents in Exploring New Models of Shared Learning: Proceedings from a DSDnet COST Action Workshop. Sex Dev 2018; 12:225-231. [PMID: 29936513 DOI: 10.1159/000490081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2018] [Indexed: 01/30/2023] Open
Abstract
The level of connection between health care professionals and people who experience a condition that affects sex development is variable. These people and associated support groups need to be included in discussions about research and healthcare delivery. The aim of this study was to understand the experiences of individuals with disorders of sexual development (DSD), their parents, health care providers, and support groups. Workshop planning, preparation, delivery, and evaluation involved members of working groups from the COST Action DSDnet. A coordinator, in collaboration with a support group representative, led the workshop design and delivery. Our successful, facilitated workshop involved 33 attendees from 8 EU countries. The workshop provided individuals with DSD, parents, advisory groups, and professionals with an opportunity for shared learning. Outputs focused on 7 key areas, including diagnosis, childhood, and transition to adult care as well as fostering discussion around registries, future research topics, consent processes, and information needs across the life course. The importance of trustworthy and knowledgeable providers, time to understand such rare conditions, and the place support groups have in a life course approach were valuable learning points for all attendees. In conclusion, workshops can be designed and delivered in meaningful ways for all those involved in care of individuals with rare conditions.
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Barseghyan H, Délot EC, Vilain E. New technologies to uncover the molecular basis of disorders of sex development. Mol Cell Endocrinol 2018; 468:60-69. [PMID: 29655603 PMCID: PMC7249677 DOI: 10.1016/j.mce.2018.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/06/2018] [Accepted: 04/06/2018] [Indexed: 02/04/2023]
Abstract
The elegant developmental biology experiments conducted in the 1940s by French physiologist Alfred Jost demonstrated that the sexual phenotype of a mammalian embryo depended whether the embryonic gonad develops into a testis or not. In humans, anomalies in the processes that regulate development of chromosomal, gonadal or anatomic sex result in a spectrum of conditions termed Disorders/Differences of Sex Development (DSD). Each of these conditions is rare, and understanding of their genetic etiology is still incomplete. Historically, DSD diagnoses have been difficult to establish due to the lack of standardization of anatomical and endocrine phenotyping procedures as well as genetic testing. Yet, a definitive diagnosis is critical for optimal management of the medical and psychosocial challenges associated with DSD conditions. The advent in the clinical realm of next-generation sequencing methods, with constantly decreasing price and turnaround time, has revolutionized the diagnostic process. Here we review the successes and limitations of the genetic methods currently available for DSD diagnosis, including Sanger sequencing, karyotyping, exome sequencing and chromosomal microarrays. While exome sequencing provides higher diagnostic rates, many patients still remain undiagnosed. Newer approaches, such as whole-genome sequencing and whole-genome mapping, along with gene expression studies, have the potential to identify novel DSD-causing genes and significantly increase total diagnostic yield, hopefully shortening the patient's journey to an accurate diagnosis and enhancing health-related quality-of-life outcomes for patients and families.
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Affiliation(s)
- Hayk Barseghyan
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA.
| | - Emmanuèle C Délot
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA.
| | - Eric Vilain
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA.
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Meoded Danon L. Time matters for intersex bodies: Between socio-medical time and somatic time. Soc Sci Med 2018; 208:89-97. [PMID: 29775964 DOI: 10.1016/j.socscimed.2018.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 04/30/2018] [Accepted: 05/06/2018] [Indexed: 11/30/2022]
Abstract
This article focuses on the dynamic relationships between time and intersex bodies that exist, on the one hand, in medical policy on intersex bodies and, on the other, in intersex people's subjective experiences. Time, from a sociological perspective, is a biosocial agent that establishes diagnostic practices, regulations, and treatment policy regarding intersex bodies. The systematic construction of timeframes by biomedical professionals aims to rapidly diagnose and treat intersex patients and is deeply rooted in the "dimorphic soma-gender order" (DMSGO), the imagined unified relationship of female bodies to femininity and male bodies to masculinity. From a socio-phenomenological perspective, I describe the concept of somatic time, which involves the relationship between time and the soma, the body's own particular clock and rhythms, according to which it grows, changes, and develops, and the body as a time capsule that stores experiences. I will illustrate the somatic time of intersex people and their subjective embodied experiences of the soma-gender relationship, and explore how their somatic time challenges biomedical timeframes. This qualitative study is based on narrative interviews with biomedical professionals, parents of intersex children, and intersex adults from Israel and Germany.
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Affiliation(s)
- Limor Meoded Danon
- The Martin Buber Society of Fellows in the Humanities and Social Sciences, The Hebrew University of Jerusalem, Mount Scopus, 9190501, Jerusalem, Israel.
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Meyer-Bahlburg HFL, Khuri J, Reyes-Portillo J, Ehrhardt AA, New MI. Stigma Associated with Classical Congenital Adrenal Hyperplasia in Women's Sexual Lives. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:943-951. [PMID: 28523454 DOI: 10.1007/s10508-017-1003-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 05/28/2023]
Abstract
The risk of intersex-related stigma often serves as social indication for "corrective" genital surgery, but has not been comprehensively documented. In preparation for the development of an intersex-specific stigma assessment tool, this qualitative project aimed to explore stigma in girls and women with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. As part of a comprehensive follow-up project, 62 adult women with classical CAH (age range 18-51 years) took part in an open-ended retrospective interview focusing on the impact of CAH and its treatment on various aspects of girls' and women's lives. Deductive qualitative content analysis (Patton, 2014) of de-identified transcripts involved categorization of three types of stigma: experienced, anticipated, and internalized. Two-fifths of the participants reported CAH-related stigma in romantic/sexual situations. Stigma enactment by romantic partners occurred in reaction to both genital and non-genital sex-atypical features of CAH and sometimes included explicit questioning of the women's true gender. Stigma anticipation by the women and their related avoidance of nudity, genital exposure, and romantic involvement altogether were frequent. Internalization of stigma occurred as well. In conclusion, the data suggest that many women with CAH experience, anticipate, and/or internalize intersex-related stigma in the context of their romantic/sexual lives.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
| | - Jananne Khuri
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Jazmin Reyes-Portillo
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Anke A Ehrhardt
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Maria I New
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Safer JD. Managing Intersex and Transgender Health Across the Globe Requires more Than Just Understanding the Science. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Szymanski KM, Whittam B, Kaefer M, Frady H, Casey JT, Tran VT, Cain MP, Rink RC. Parental decisional regret and views about optimal timing of female genital restoration surgery in congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:156.e1-156.e7. [PMID: 29330019 DOI: 10.1016/j.jpurol.2017.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The role of female genital restoration surgery (FGRS) in girls with congenital adrenal hyperplasia (CAH) is controversial, with no long-term parent-reported outcomes available. Decisional regret (DR) affects most parents after their children's treatment of pediatric conditions, including hypospadias. We aimed to assess parental DR after FGRS in infancy or toddlerhood and explore optimal timing for surgery. MATERIALS AND METHODS One-hundred and six parents of females with CAH undergoing FGRS before 3 years old and followed at our institution (1999-2017) were invited to enroll online. Higher Decision Regret Scale (DRS) scores indicated greater DR (range 0-100). Participants also reported preferred FGRS timing relative to their surgery (earlier, same, later/delayed). Non-parametric statistical tests were used. RESULTS Thirty-nine parents (median 4.4 years after FGRS) participated (36.8% response rate). Median age at FGRS was 9 months. Median DRS score was 0 (mean: 5.0). Overall, 20.5% of parents reported some regret (all mild-moderate) (Figure). Fewer parents reported DR after FGRS compared with published DR after hypospadias repair (50-92%, p ≤ 0.001) or adenotonsillectomy (41-45%, p ≤ 0.03). No parent preferred delayed FGRS. Seven parents (18.1%) preferred earlier surgery, especially when performed after birthday (80.0% vs. 8.8%, p = 0.004). DISCUSSION We present the first report of validated long-term parent-reported outcomes after FGRS in infant and toddler girls with CAH. One limitation is that this is largely a single surgeon series. Reasons for the observed low levels of DR are likely multifactorial. Far from a definitive study, we aimed to provide parents willing to share about their experience an opportunity to do so. For that reason, selection bias may exist in our study. While parents with higher DR were potentially less likely to participate because of mistrust of the medical establishment, those with a negative experience may in fact be more likely to voice their opinions. A low participation rate was likely a result of the sensitive nature of FGRS, a desire for privacy, and inability to locate parents. A larger study will be required to assess how DR is affected by sexual function, genital appearance and complications, and DR among women with CAH. CONCLUSIONS Parents of females with CAH report low levels of DR after FGRS in infancy and toddlerhood. This appears to be lower than after other genital and non-genital pediatric procedures. When present, parental DR is usually mild. No parents preferred delayed surgery, even among those with DR. Some preferred earlier surgery.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA.
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Martin Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Heather Frady
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Jessica T Casey
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Vi T Tran
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Mark P Cain
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
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Ferrara M, Casper MJ. Genital Alteration and Intersex: a Critical Analysis. CURRENT SEXUAL HEALTH REPORTS 2018. [DOI: 10.1007/s11930-018-0142-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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González R, Ludwikowski BM. Is It Beneficial to Patients to Include Congenital Adrenal Hyperplasia (CAH) Among the Disorders of Sex Development (DSD)? Front Pediatr 2018; 6:344. [PMID: 30483487 PMCID: PMC6240692 DOI: 10.3389/fped.2018.00344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Kinder-und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Kinder-und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
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Alpern AN, Gardner M, Kogan B, Sandberg DE, Quittner AL. Development of Health-Related Quality of Life Instruments for Young Children With Disorders of Sex Development (DSD) and Their Parents. J Pediatr Psychol 2017; 42:544-558. [PMID: 27026663 DOI: 10.1093/jpepsy/jsw022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/01/2016] [Indexed: 11/13/2022] Open
Abstract
Objective Research in disorders of sex development (DSD) is hindered by a lack of standardized measures sensitive to the experiences of affected children and families. We developed and evaluated parent proxy (children 2-6 years) and parent self-report (children ≤6 years) health-related quality of life (HRQoL) instruments for DSD. Methods Items were derived from focus groups and open-ended interviews. Clarity and comprehensiveness were assessed with cognitive interviews. Psychometric properties were examined in a field survey of 94 families. Results Measures demonstrated adequate to good psychometrics, including internal consistency, test-retest reliability, convergent validity, and ability to detect known-group differences. Parents reported greatest stress on Early Experiences , Surgery , and Future Concerns scales. Conclusions These instruments identify patients' and families' needs, monitor health and quality of life status, and can evaluate clinical interventions. Findings highlight the need for improved psychosocial support during the diagnostic period, better parent-provider communication, and shared decision-making. HRQoL measures are needed for older youth.
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Affiliation(s)
- Adrianne N Alpern
- Department of Psychology, University of Miami, Ponce De Leon Blvd., Coral Gables, FL, USA
| | - Melissa Gardner
- Department of Pediatrics; Division of Pediatric Psychology and Child Health Evaluation & Research (CHEAR) Unit, University of Michigan, Ann Arbor, Michigan, USA
| | - Barry Kogan
- Division of Urology, Albany Medical College, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics; Division of Pediatric Psychology and Child Health Evaluation & Research (CHEAR) Unit, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexandra L Quittner
- Department of Psychology, University of Miami, Ponce De Leon Blvd., Coral Gables, FL, USA
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Liang JJ, Gardner IH, Walker JA, Safer JD. OBSERVED DEFICIENCIES IN MEDICAL STUDENT KNOWLEDGE OF TRANSGENDER AND INTERSEX HEALTH. Endocr Pract 2017; 23:897-906. [PMID: 28534684 DOI: 10.4158/ep171758.or] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients face many well-documented disparities in care which among transgender and intersex people can often be traced to providers' lack of knowledge. METHODS We administered surveys to examine the self-assessed knowledge and attitudes of all medical students at Boston University regarding different LGBTI subpopulations. Survey questions were based on a Likert scale from 1 to 5; analysis was conducted with Wilcoxon rank sum tests. RESULTS Overall there was a response rate of 24%, with the number of responses varying by class. Three of the 4 surveyed classes reported lower knowledge about transgender health than LGB health. Every class reported significantly lower knowledge of intersex health in comparison to LGB. Comfort with transgender or with intersex patients was lower than with LGB patients for all surveyed classes. Students across all self-identified groups (LGBTI, ally, not an ally) reported significantly lower average responses for knowledge and comfort regarding transgender or intersex health in comparison to that of LGB. Students in their preclinical years reported lower levels of knowledge in comparison with students in their clinical years. Students who identified as LGBTI reported significantly higher knowledge and comfort with only LGB and transgender health when compared with students who didn't identify as LGBTI. Respondents more frequently requested additional learning opportunities in transgender and intersex health than in LGB health. CONCLUSION Self-reported knowledge of transgender and intersex health lags behind knowledge of LGB health, though these deficits appear partially responsive to targeted educational intervention. ABBREVIATIONS BUSM = Boston University School of Medicine LGB = lesbian, gay, and bisexual LGBT = lesbian, gay, bisexual, and transgender LGBTI = lesbian, gay, bisexual, transgender, and intersex M1 = first-year medical student class M2 = second-year medical student class M3 = third-year medical student class M4 = fourth-year medical student class.
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Meyer-Bahlburg HFL, Reyes-Portillo JA, Khuri J, Ehrhardt AA, New MI. Syndrome-Related Stigma in the General Social Environment as Reported by Women with Classical Congenital Adrenal Hyperplasia. ARCHIVES OF SEXUAL BEHAVIOR 2017; 46:341-351. [PMID: 27677267 DOI: 10.1007/s10508-016-0862-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 09/02/2016] [Accepted: 09/08/2016] [Indexed: 05/28/2023]
Abstract
Stigma defined as "undesired differentness" (Goffman, 1963) and subtyped as "experienced" or "enacted," "anticipated," and "internalized" has been documented for patients with diverse chronic diseases. However, no systematic data exist on the association of stigma with somatic intersexuality. The current report concerns women with classical congenital adrenal hyperplasia (CAH), the most prevalent intersex syndrome, and provides descriptive data on CAH-related stigma as experienced in the general social environment (excluding medical settings and romantic/sexual partners) during childhood, adolescence, and adulthood. A total of 62 adult women with classical CAH [41 with the salt-wasting (SW) variant and 21 with the simple-virilizing (SV) variant] underwent a qualitative retrospective interview, which focused on the impact of CAH and its medical treatment on many aspects of women's lives. Deductive content analysis was performed on the transcribed texts. The women's accounts of CAH-related stigma were identified and excerpted as vignettes, and the vignettes categorized according to social context, stigma type, and the associated features of the CAH condition. Nearly two-thirds of women with either variant of CAH provided stigma vignettes. The vignettes included all three stigma types, and most involved some somatic or behavioral feature related to sex or gender. Stigma situations were reported for all ages and all social contexts of everyday life: family, peers, colleagues at work, strangers, and the media. We conclude that there is a need for systematic documentation of stigma in intersexuality as a basis for the development of improved approaches to prevention and intervention.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
| | - Jazmin A Reyes-Portillo
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Jananne Khuri
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Anke A Ehrhardt
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Maria I New
- Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA
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Eckstrand KL, Potter J, Bayer CR, Englander R. Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:930-5. [PMID: 26796092 PMCID: PMC4925271 DOI: 10.1097/acm.0000000000001088] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee's process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.
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Affiliation(s)
- Kristen L Eckstrand
- K.L. Eckstrand is a psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and founding chair, Association of American Medical Colleges, Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Washington, DC. J. Potter is associate professor of medicine, Harvard Medical School, Cambridge, Massachusetts, and director, Women's Health Research, Fenway Institute, Boston, Massachusetts. C.R. Bayer is associate professor, Morehouse School of Medicine, and associate director of educational leadership, Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia. R. Englander was senior director of competency-based learning and assessment, Association of American Medical Colleges, and is currently adjunct professor of pediatrics, George Washington School of Medicine, Washington, DC
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Abstract
Great controversies and misunderstandings have developed around the relatively recently coined term disorders of sex development (DSD). In this article, we question the wisdom of including XX individuals with congenital adrenal hyperplasia (CAH) in the DSD category and develop arguments against it based on the published literature on the subject. It is clear that females with CAH assigned the female gender before 24 months of age and properly managed retain the female gender identity regardless of the Prader grade. Females with CAH and low Prader grades have the potential for a normal sexual and reproductive life. Those with greater degrees of prenatal androgen exposure (Prader grades IV and V) raised as females also identify themselves as females but experience more male-like behavior in childhood, have a greater rate of homosexuality, and have greater difficulty with vaginal penetration and maintaining pregnancies. Improvement in surgical techniques, better endocrinological, psychological, and surgical follow-up may lessen these problems in the future. Given the fact that the term DSD includes many conditions with problematic gender identity and conflicts with the gender assigned at birth, it may be appropriate to exclude females with CAH from the DSD classification.
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Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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41
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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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McCracken KA, Fallat ME. Transition from pediatric to adult surgery care for patients with disorders of sexual development. Semin Pediatr Surg 2015; 24:88-92. [PMID: 25770370 DOI: 10.1053/j.sempedsurg.2015.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disorders of sexual development (DSDs) are relatively rare congenital conditions in which the development of the chromosomal, gonadal, or anatomic sex is atypical. Some conditions may not manifest until puberty or adulthood. The examination and workup of either an infant or an older patient with suspected DSD should be directed and performed systematically by a multidisciplinary team. Ideally, the team will include those with not only an interest in DSD but also experience with this group of patients. This article will briefly orient the reader to the conditions and decisions that may have been made during infancy, childhood, and adolescence and then focus on the challenges that may accompany transitioning the care of DSD patients from pediatric to adult surgeons and specialists to enable appropriate decisions and care. The actual transition will optimally involve a well-developed action plan that will take place gradually over a number of years as the person becomes educated about their condition and empowered to participate knowingly and actively in their own care.
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Affiliation(s)
- Kate A McCracken
- Kosair Children's Hospital, Norton Healthcare, Louisville, Kentucky 40202
| | - Mary E Fallat
- Division of Pediatric Surgery, Kosair Children's Hospital, Louisville, Kentucky; Department of Surgery, Division Chief of Pediatric Surgery, University of Louisville, 315 East Broadway, Suite 565, Louisville, Kentucky 40202.
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Abstract
Mammalian sex determination is the unique process whereby a single organ, the bipotential gonad, undergoes a developmental switch that promotes its differentiation into either a testis or an ovary. Disruptions of this complex genetic process during human development can manifest as disorders of sex development (DSDs). Sex development can be divided into two distinct processes: sex determination, in which the bipotential gonads form either testes or ovaries, and sex differentiation, in which the fully formed testes or ovaries secrete local and hormonal factors to drive differentiation of internal and external genitals, as well as extragonadal tissues such as the brain. DSDs can arise from a number of genetic lesions, which manifest as a spectrum of gonadal (gonadal dysgenesis to ovotestis) and genital (mild hypospadias or clitoromegaly to ambiguous genitalia) phenotypes. The physical attributes and medical implications associated with DSDs confront families of affected newborns with decisions, such as gender of rearing or genital surgery, and additional concerns, such as uncertainty over the child's psychosexual development and personal wishes later in life. In this Review, we discuss the underlying genetics of human sex determination and focus on emerging data, genetic classification of DSDs and other considerations that surround gender development and identity in individuals with DSDs.
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Affiliation(s)
- Valerie A Arboleda
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, 695 Charles E. Young Drive South, Los Angeles, CA 90095-7088, USA
| | - David E Sandberg
- Department of Pediatrics, Division of Child Behavioral Health and Child Health Evaluation &Research (CHEAR) Unit, University of Michigan, 300 North Ingalls Street, Ann Arbor, MI 48109-5456, USA
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, 695 Charles E. Young Drive South, Los Angeles, CA 90095-7088, USA
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Garland J, Diamond M. Response to 'Re. Evidence regarding cosmetic and medically unnecessary surgery on infants'. J Pediatr Urol 2014; 10:977-8. [PMID: 25155164 DOI: 10.1016/j.jpurol.2014.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Affiliation(s)
| | - Milton Diamond
- John Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Hiort O, Birnbaum W, Marshall L, Wünsch L, Werner R, Schröder T, Döhnert U, Holterhus PM. Management of disorders of sex development. Nat Rev Endocrinol 2014; 10:520-9. [PMID: 25022812 DOI: 10.1038/nrendo.2014.108] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The medical term disorders of sex development (DSDs) is used to describe individuals with an atypical composition of chromosomal, gonadal and phenotypic sex, which leads to differences in the development of the urogenital tract and reproductive system. A variety of genetic factors have been identified that affect sex development during gonadal differentiation or in specific disorders associated with altered androgen biosynthesis or action. The diagnosis of DSDs in individuals and the subsequent management of patients and their families requires a targeted and structured approach, involving a multidisciplinary team with effective communication between the disciplines. This approach includes distinct clinical, imaging, laboratory and genetic evaluations of patients with DSDs. Although treatment of patients with DSDs can include endocrine and surgical options, many patients have concerns that arise from past incorrect treatments that were founded on the traditional binary concept of the sexes. To dispel these concerns, it is necessary to create centres of expertise for DSDs that include physicians, surgeons, psychologists and specialists in diagnostic procedures to manage patients and their families. Additionally, the inclusion of trained peer support in the multidisciplinary DSD team seems to be integral to the supportive management of patients with DSDs. Most importantly, dealing with DSDs requires acceptance of the fact that deviation from the traditional definitions of gender is not necessarily pathologic.
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Affiliation(s)
- Olaf Hiort
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Wiebke Birnbaum
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Louise Marshall
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Lutz Wünsch
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Tatjana Schröder
- Department of Gynaecology and Obstetrics, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ulla Döhnert
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Christian-Albrechts-University, Schwanenweg 20, 24105 Kiel, Germany
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Tamar-Mattis A. Patient advocate responds to DSD surgery debate. J Pediatr Urol 2014; 10:788-9. [PMID: 24909610 DOI: 10.1016/j.jpurol.2014.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 11/17/2022]
Affiliation(s)
- A Tamar-Mattis
- Advocates for Informed Choice, POB 676, Cotati, CA 94931, United States.
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Lee PA, Houk CP. Commentary to 'Evidence regarding cosmetic and medically unnecessary surgery on infants'. J Pediatr Urol 2014; 10:7. [PMID: 24528670 DOI: 10.1016/j.jpurol.2013.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/01/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Peter A Lee
- Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA.
| | - Christopher P Houk
- Georgia Health Sciences University, 1120 15th St., Augusta, GA 30912,USA.
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48
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González R, Ludwikowski BM. Should the Genitoplasty of Girls with CAH be Done in One or Two Stages? Front Pediatr 2014; 1:54. [PMID: 24455666 PMCID: PMC3887265 DOI: 10.3389/fped.2013.00054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 12/30/2013] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder - und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder - und Jugendkrankenhaus , Hannover , Germany
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