1
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Kamoun C, Rossi W, Kilberg MJ. Ethical concerns surrounding sex prediction using noninvasive prenatal screening from pediatric endocrinologists' perspective. J Genet Couns 2023; 32:937-941. [PMID: 37401532 PMCID: PMC10581910 DOI: 10.1002/jgc4.1649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/14/2022] [Accepted: 10/15/2022] [Indexed: 07/05/2023]
Abstract
Noninvasive prenatal screening (NIPS) with predicted fetal sex chromosomes included in the results has become increasingly available for pregnant individuals. Predicted fetal sex chromosome results from NIPS are interpreted so as to equate sex chromosomes with sex and gender. As pediatric endocrinologists, we worry about how this use of NIPS harmfully reinforces sex and gender binaries and sets potentially inaccurate assumptions about what the identified chromosomes mean. We use a hypothetical case based on our clinical experience in which the NIPS report of fetal sex does not conform to expectations at birth to highlight ethical concerns surrounding this practice. The use of NIPS for fetal sex chromosome prediction has the potential to perpetuate stigma and bring psychological harm to parents and their future children, particularly those who are intersex, transgender, and gender diverse. The medical community should adopt an approach to the use of NIPS for fetal sex chromosome prediction that recognizes the spectrums of sex and gender to avoid reproducing stigma towards sex- and gender-diverse individuals and associated harms.
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Affiliation(s)
- Camilia Kamoun
- Division of Pediatric Endocrinology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Wilma Rossi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marissa J Kilberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Griffin LB, McCarthy M, Russo ML. Navigation of Prenatal Care With Sex Discordance Between Cell-free DNA and Ultrasound Findings. Clin Obstet Gynecol 2023; 66:616-623. [PMID: 37650671 DOI: 10.1097/grf.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The utilization of cell-free DNA (cfDNA) screening has expanded rapidly across the age spectrum of pregnant persons. With cfDNA's widespread adoption, genetic fetal sex is now often known before a phenotypic assessment on anatomic survey. CfDNA detects sex discordance in 1/1500 to 2000 pregnancies. Upon detection of sex discordance, lab error or other factors should first be assessed. Once other causes have been ruled out, this may indicate an underlying disorder/difference in sex development. A multidisciplinary team should coordinate diagnosis, treatment, and support for the family. This review discusses the diagnostic workup, emphasizing the multidisciplinary counseling and management of disorder/differences in sex development.
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Affiliation(s)
- Laurie B Griffin
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
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3
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Chen K, Dunleavy BM, Talreja KL, Jones R. Differences of sexual development: genetic counseling considerations in the prenatal setting. Curr Opin Obstet Gynecol 2023; 35:127-133. [PMID: 36912347 DOI: 10.1097/gco.0000000000000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW With the rapid adoption of noninvasive prenatal screening (NIPS), predictive fetal sex information is available early in pregnancy. This information can conflict with the results of other prenatal tests such as fetal ultrasound or diagnostic testing and raise the possibility of a fetal difference of sexual development (DSD). In this review, we describe recent studies examining the counseling and outcomes of prenatally suspected DSD. RECENT FINDINGS Discordance in prenatal genetic testing results can cause confusion and anxiety in families as expectations of testing are not often discussed in detail prior to testing. There are no established guidelines for the counseling or management of such situations. SUMMARY We present case vignettes to highlight relevant counseling points and considerations to aid in the development of guidelines and best practices in the management of DSD in the prenatal setting.
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Affiliation(s)
| | | | - Karina L Talreja
- Perinatal Genetics, Stanford Medicine Children's Health, Palo Alto
| | - Renee Jones
- Roche Diagnostic Solutions, Clinical Development and Medical Affairs, Pleasanton, California
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4
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van Bever Y, Groenenberg IAL, Knapen MFCM, Dessens AB, Hannema SE, Wolffenbuttel KP, Diderich KEM, Hoefsloot LH, Srebniak MI, Bruggenwirth HT. Prenatal ultrasound finding of atypical genitalia: Counseling, genetic testing and outcomes. Prenat Diagn 2023; 43:162-182. [PMID: 35808910 DOI: 10.1002/pd.6205] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To report uptake of genetic counseling (GC) and prenatal genetic testing after the finding of atypical genitalia on prenatal ultrasound (US) and the clinical and genetic findings of these pregnancies. METHODS A retrospective cohort study (2017-2019) of atypical fetal genitalia in a large expert center for disorders/differences of sex development. We describe counseling aspects, invasive prenatal testing, genetic and clinical outcome of fetuses apparently without [group 1, n = 22 (38%)] or with [group 2, n = 36 (62%)] additional anomalies on US. RESULTS In group 1, 86% of parents opted for GC versus 72% in group 2, and respectively 58% and 15% of these parents refrained from invasive testing. Atypical genitalia were postnatally confirmed in 91% (group 1) and 64% (group 2), indicating a high rate of false positive US diagnosis of ambiguous genitalia. Four genetic diagnoses were established in group 1 (18%) and 10 in group 2 (28%). The total genetic diagnostic yield was 24%. No terminations of pregnancy occurred in group 1. CONCLUSIONS For optimal care, referral for an expert fetal US scan, GC and invasive diagnostics including broad testing should be offered after prenatal detection of isolated atypical genitalia.
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Affiliation(s)
- Yolande van Bever
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Irene A L Groenenberg
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maarten F C M Knapen
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Arianne B Dessens
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Sabine E Hannema
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Pediatric Endocrinology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Paediatric Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Katja P Wolffenbuttel
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Karin E M Diderich
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lies H Hoefsloot
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Malgorzata I Srebniak
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hennie T Bruggenwirth
- DSD-Expert Center, Erasmus MC, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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5
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Whitehead J, Hirsch J, Rosoklija I, Weisman AG, Dungan J, Finlayson C, Chen D, Johnson EK. Prenatal Detection and Evaluation of Differences of Sex Development: A Qualitative Interview Study of Parental Perspectives and Unmet Needs. Prenat Diagn 2022; 42:1332-1342. [PMID: 35670269 PMCID: PMC9545652 DOI: 10.1002/pd.6191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/11/2022]
Abstract
Objectives Prenatal diagnoses of differences of sex development (DSD) are increasing due to availability of cell‐free DNA screening (cell‐free DNA screening (cfDNA)). This study explores first‐hand experiences of parents whose children had prenatal findings of DSD. Methods Eligible parents were identified through chart review at a pediatric center and interviewed about their prenatal evaluation, decision making, informational sources, and support systems. Interviews were coded using a combined inductive and deductive thematic analysis. Parents also completed quantitative measures of decisional regret. Results Seventeen parents (13 mothers; 4 fathers) of 13 children (with 7 DSD diagnoses) were recruited. Four children had discordance between sex predicted by cfDNA versus prenatal ultrasound, and 2 had non‐binary appearing (atypical) genitalia on prenatal ultrasound. Of these 6, 3 were not offered additional prenatal testing or counseling. Most parents described tension between obtaining support through disclosure of their child's diagnosis and preserving their child's autonomy/privacy, highlighting the need for mental health support. Conclusion This is the first study to gather qualitative data from parents whose children had prenatal findings of DSD. We identified multiple targets for intervention to improve care for patients with DSD across the lifespan, including improvements in clinician education, pre‐ and post‐test counseling, and patient education materials.
What's already known about this topic? What does this study add?
Prenatal detection of potential differences of sex development (DSD) is increasing as the availability of non‐invasive prenatal screening increases. Algorithms have been developed for the diagnostic evaluation, but little is known about the psychosocial implications of that process. This study focuses on the first‐hand experiences of families whose children had prenatal findings of a potential DSD, to identify existing sources of support and information, and areas for future improvement.
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Affiliation(s)
- J Whitehead
- Division of Endocrinology, Chicago, United States.,Department of Pediatrics, Chicago, United States
| | | | | | | | | | - Courtney Finlayson
- Division of Endocrinology, Chicago, United States.,Department of Pediatrics, Chicago, United States
| | - Diane Chen
- Adolescent & Young Adult Medicine, Chicago, United States.,Department of Psychiatry & Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Chicago, United States.,Psychiatry & Behavioral Sciences, Chicago, United States
| | - Emilie K Johnson
- Urology, Chicago, United States.,Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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6
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Sofer L, D'Oro A, Rosoklija I, Leeth EA, Goetsch AL, Moses S, Chen D, Finlayson C, Johnson EK. Impact of cell-free DNA screening on parental knowledge of fetal sex and disorders of sex development. Prenat Diagn 2020; 40:1489-1496. [PMID: 32683746 DOI: 10.1002/pd.5801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/01/2020] [Accepted: 07/14/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Discrepancies between cfDNA and ultrasound predicted fetal sex occur, possibly indicating disorders/differences of sex development (DSDs). Among expectant/recent parents, this study assessed cfDNA knowledge/use, fetal sex determination attitudes/behaviors, general knowledge of DSD, and possible psychological impact of discrepancy between fetal sex on cfDNA and ultrasound. METHOD Parents were surveyed about fetal sex determination methods, knowledge of cfDNA and DSD, distress related to possible cfDNA inaccuracy. RESULTS Of 916 respondents, 44% were aware of possible discrepancy between cfDNA and ultrasound, 22% were aware of DSD. 78% and 75% would be upset and worried, respectively, with results showing fetal sex discrepancy. Most (67%) revealed predicted fetal sex before delivery. 38% were offered cfDNA. Of those revealing fetal sex, 24% used cfDNA results, 71% ultrasound, and 7% both. cfDNA users were more frequently aware of possible discrepancy between cfDNA and ultrasound (76% vs 41%, P < .0001), but not of DSD (29% vs 23%, P = .29). CONCLUSION Fetal sex determination is favored, and cfDNA is frequently used for predicting fetal chromosomal sex. Many parents are unaware of possible discrepancies between cfDNA and ultrasound, and potential for DSD. Most would be distressed by discordant results. Accurate counseling regarding limitations cfDNA for fetal sex determination is needed.
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Affiliation(s)
- Laurel Sofer
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Anthony D'Oro
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Elizabeth A Leeth
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Graduate Program in Genetic Counseling, Northwestern University, Chicago, Illinois, USA
| | - Allison L Goetsch
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Graduate Program in Genetic Counseling, Northwestern University, Chicago, Illinois, USA
| | - Scott Moses
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Diane Chen
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Courtney Finlayson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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7
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Sato T, Ishii T, Yamaguchi Y, Ichihashi Y, Ochiai D, Asanuma H, Kuroda T, Hasegawa T. Case Report: Prenatal Genetic Counseling to Parents of Fetuses Suspected of Having Ambiguous Genitalia. Front Pediatr 2020; 8:569548. [PMID: 33520882 PMCID: PMC7838588 DOI: 10.3389/fped.2020.569548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
The occurrence of fetuses suspected of having ambiguous genitalia will likely increase in the future. Currently, the impact of prenatal genetic counseling on parents' understanding and psychological preparedness has not been addressed. We provided prenatal genetic counseling to parents of two fetuses suspected of ambiguous genitalia. Case 1: At 22 weeks of gestation, swelling of the labia majora, and a clitoris-like structure were noted despite 46,XY detected in amniotic fluid cells. Case 2: At 28 weeks of gestation, bladder exstrophy and a scrotum-like structure were noted. At 32 weeks (Case 1) and 37 weeks (Case 2) of gestation, we shared information with parents regarding the possible difficulty of legal sex assignment at birth, and a scenario for registration of the birth certificate. At birth, both babies presented with ambiguous genitalia. For both cases, the parents remained calm on seeing their baby's genitalia for the first time. After a month, we shared medical information with parents, including karyotype, testosterone production capacity, and surgical schedule. In both cases parents assigned their respective baby's legal sex as male. Several months later, parents were questioned on prenatal genetic counseling. Case 1: Mother, "I was prepared to address our baby's genitalia calmly." Father, "I understood the procedure of legal sex assignment." Case 2: Mother, "Without counseling, I would have been more upset and worried." Father, "We were assured that multidisciplinary experts would support us." Prenatal genetic counseling provides reassurance to parents, who remain informed and emotionally secure throughout the legal sex assignment of their child.
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Affiliation(s)
- Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Yu Yamaguchi
- Department of Clinical Genetics, Gunma Children's Medical Center, Gunma, Japan
| | - Yosuke Ichihashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Daigo Ochiai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Asanuma
- The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan.,Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan.,Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
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