1
|
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.
Collapse
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
| |
Collapse
|
2
|
Kalfa N, Nordenström J, De Win G, Hoebeke P. Adult outcomes of urinary, sexual functions and fertility after pediatric management of differences in sex development: Who should be followed and how? J Pediatr Urol 2024; 20:367-375. [PMID: 38423920 DOI: 10.1016/j.jpurol.2024.01.022] [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: 07/27/2023] [Revised: 12/19/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.
Collapse
Affiliation(s)
- Nicolas Kalfa
- Département de Chirurgie Infantile, Service de Chirurgie Viscérale et Urologie Pédiatrique, CHU de Montpellier, Montpellier, France; Centre de Référence Maladies Rares DEVGEN Constitutif Sud, CHU de Montpellier, Montpellier, France; UMR 1302 Institute Desbrest of Epidemiology and Public Health, INSERM, Univ Montpellier, Montpellier, France.
| | - Josefin Nordenström
- Department of Pediatric Surgery/Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunter De Win
- Department of Urology, University Hospital Antwerp, Edegem, Belgium; Astarc, Faculty of Medicine and Health Science, University of Antwerp, Belgium; Adolescenty Urology, University College London Hospitals, London, UK
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| |
Collapse
|
3
|
Ibrahim H, Lachkar AA, Bidault V, Delcour C, Paye-Jaouen A, Peycelon M, El-Ghoneimi A. Genito-urinary Reconstruction in Female Children With Congenital Adrenal Hyperplasia: Favorable Surgical Outcomes can be Achieved by Contemporary Techniques and a Dedicated Multidisciplinary Management. J Pediatr Surg 2024:S0022-3468(24)00310-5. [PMID: 38902168 DOI: 10.1016/j.jpedsurg.2024.05.009] [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: 01/02/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Congenital adrenal hyperplasia (CAH) is the most common cause of genital atypia in females. A dedicated multidisciplinary team (MDT) should be included for an optimal management. Here, we aimed to review our surgical experience and to assess long-term urinary, gynecological and endocrine outcomes after primary genitoplasty in this specific cohort. METHODS Patients born with CAH and who underwent feminizing genitoplasty in our institution were retrospectively identified (2001-2021). We analyzed patients' characteristics, intraoperative details, and postoperative urinary, gynecological, and endocrine outcomes. RESULTS Forty patients were included and followed-up for a median (IQR) time of 7 (1-19) years. Thirty-eight (95%) had 21-hydroxylase deficiency. After multidisciplinary decision and written consent from patient and/or family, a single-stage reconstructive surgery was performed at a median age of 10 (3-165) months. Median length of hospital stay was 5 (1-7) days. Procedures were: PUM (N = 35 (87.5%)), TUM (N = 3 (7.5%)), urogenital mobilization was unnecessary in 2 (5%). Reduction clitoroplasty was done in 33 (82.5%) patients. Only 3 (7.5%) experienced significant Clavien-Dindo complications requiring additional surgery during the follow-up period. Recurrent urinary tract infections (UTI) occurred in 6 (15%), one required ureteric reimplantation for symptomatic high-grade vesicoureteric reflux. All patients over 3 years were toilet-trained without incontinence. Severe vaginal stenosis occurred in 1 (2.5%) patient. In patients who achieved puberty, 6/9 had vaginal calibration at a median age of 17.3 (16-21) years without detected stenosis. One (2.5%) had major hypertrophy of the right labia minora requiring labiaplasty. Nine (22.5%) reached puberty. Two (5%) patients developed acne/hirsutism. Short stature was noted in 11 (27.5%) and obesity in 18 (45%). CONCLUSION Based on our contemporary series, genitourinary reconstructive surgery for female patients born with CAH is technically feasible and safe with a low complication rate. A regular follow-up with a MDT to assess long-term complications is necessary, and it is vital to inform patients and families about the different management options with all the risks and benefits of surgery. TYPE OF THE STUDY original research, clinical research. LEVEL OF EVIDENCE Level 3 retrospective study.
Collapse
Affiliation(s)
- Hussein Ibrahim
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France; Pediatric Surgery Unit, Assiut University Children Hospital, Assiut, Egypt
| | - Amane-Allah Lachkar
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Valeska Bidault
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Clemence Delcour
- Department of Gynecology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France.
| |
Collapse
|
4
|
Neeman BB, Jaber J, Kocherov S, Levy-Khademi F, Farkas A, Chertin B. Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society. J Pediatr Urol 2024:S1477-5131(24)00189-X. [PMID: 38631940 DOI: 10.1016/j.jpurol.2024.03.033] [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: 11/02/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. METHODS We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. RESULTS we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9 ± 4.7 years (mean ± SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1 ± 8.2 years (mean ± SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3β-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. CONCLUSIONS Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.
Collapse
Affiliation(s)
- Binyamin B Neeman
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel.
| | - Jawdat Jaber
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Stanislav Kocherov
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Floris Levy-Khademi
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Amicur Farkas
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | - Boris Chertin
- Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| |
Collapse
|
5
|
Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
Collapse
Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| |
Collapse
|
6
|
Dwiggins M, Brookner B, Fowler K, Veeraraghavan P, Gomez-Lobo V, Merke DP. Multidimensional Aspects of Female Sexual Function in Congenital Adrenal Hyperplasia: A Case-Control Study. J Endocr Soc 2020; 4:bvaa131. [PMID: 34485799 DOI: 10.1210/jendso/bvaa131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/28/2020] [Indexed: 11/19/2022] Open
Abstract
Context 46,XX patients with classic congenital adrenal hyperplasia (CAH) are exposed to elevated androgens in utero causing varying levels of virilization. The majority undergo feminizing genitoplasty early in life, with potential impact on sexual function and health-related quality of life (HRQoL). Objective We aimed to determine how sexual and lower urinary tract function, body image, and global HRQoL differs between patients with classic CAH and controls and to characterize how gynecologic anatomy contributes to outcomes. Methods 36 patients with classic CAH and 27 control women who were matched for age, race, and marital status underwent standardized gynecological examination and validated questionnaires. The responses were analyzed in relation to gynecological measurements, genotype, and disease status. Results Compared with controls, patients with CAH were more likely to have sexual dysfunction (P = 0.009), dyspareunia (P = 0.007), and other pelvic pain (P = 0.007); were less likely to be heterosexual (P = 0.013) or ever have been sexually active (P = 0.003); had poorer body image independent of body mass index (P < 0.001); and had worse HRQoL in the areas of general health (P = 0.03) and pain (P = 0.009). The patients with CAH had smaller vaginal calibers and perineal body lengths and larger clitoral indexes when compared with controls (P < 0.001). A larger vaginal caliber in CAH patients was associated with better overall sexual function (P = 0.024), increased sexual satisfaction (P = 0.017), less pain (P < 0.001), and greater number of sexual partners (P = 0.02). Conclusions 46,XX patients with CAH have increased rates of sexual dysfunction, poor body image, and poor HRQoL, which is mitigated by having a larger vaginal caliber. Management aimed at optimizing vaginal caliber might improve sexual function.
Collapse
Affiliation(s)
- Maggie Dwiggins
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Norton Children's Medical Group, Louisville, Kentucky
| | | | - Kylie Fowler
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Children's Minnesota, Minneapolis, Minnesota
| | | | - Veronica Gomez-Lobo
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|