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Adriaansen BPH, Utari A, Westra D, Juniarto AZ, Ariani MD, Ediati A, Schröder MAM, Span PN, Sweep FCGJ, Drop SLS, Faradz SMH, van Herwaarden AE, Claahsen – van der Grinten HL. 46,XX males with congenital adrenal hyperplasia: a clinical and biochemical description. Front Endocrinol (Lausanne) 2024; 15:1410122. [PMID: 39175568 PMCID: PMC11338787 DOI: 10.3389/fendo.2024.1410122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/23/2024] [Indexed: 08/24/2024] Open
Abstract
Introduction Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) or 11-hydroxylase deficiency (11OHD) is characterized by underproduction of cortisol and overproduction of adrenal androgens. These androgens lead to a variable degree of virilization of the female external genitalia in 46,XX individuals. Especially in developing countries, diagnosis is often delayed and 46,XX patients might be assigned as males. This study aims to describe the clinical and biochemical characteristics of a unique cohort of untreated male-reared 46,XX classic CAH patients from Indonesia and discusses treatment challenges. Methods Nine untreated classic CAH patients with 46,XX genotype and 21OHD (n=6) or 11OHD (n=3), aged 3-46 years old, were included. Biometrical parameters, clinical characteristics, and biochemical measurements including glucocorticoids, renin, androgens, and the pituitary-gonadal axis were evaluated. Results All patients had low early morning serum cortisol concentrations (median 89 nmol/L) without significant increase after ACTH stimulation. Three patients with salt wasting 21OHD reported one or more periods with seizures and/or vomiting in their past until the age of 6, but not thereafter. The remaining patients reported no severe illness or hospitalization episodes, despite their decreased capacity to produce cortisol. In the 21OHD patients, plasma renin levels were elevated compared to the reference range, and in 11OHD patients renin levels were in the low-normal range. All adult patients had serum testosterone concentrations within the normal male reference range. In 21OHD patients, serum 11-oxygenated androgens comprised 41-60% of the total serum androgen concentrations. Glucocorticoid treatment was offered to all patients, but they refused after counseling as this would reduce their endogenous androgen production and they did not report complaints of their low cortisol levels. Discussion We describe a unique cohort of untreated classic 46,XX male CAH patients without overt clinical signs of cortisol deficiency despite their cortisol underproduction and incapacity to increase cortisol levels after ACTH stimulation. The described adolescent and adult patients produce androgen levels within or above the normal male reference range. Glucocorticoid treatment will lower these adrenal androgen concentrations. Therefore, in 46,XX CAH patients reared as males an individual treatment approach with careful counseling and clear instructions is needed.
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Affiliation(s)
- Bas P. H. Adriaansen
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Agustini Utari
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Department of Pediatrics, Division of Pediatric Endocrinology, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Dineke Westra
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Achmad Zulfa Juniarto
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Mahayu Dewi Ariani
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | | | - Mariska A. M. Schröder
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N. Span
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C. G. J. Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Stenvert L. S. Drop
- Department of Pediatrics, Division of Endocrinology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Sultana M. H. Faradz
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | | | - Hedi L. Claahsen – van der Grinten
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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Muacevic A, Adler JR. Challenges in the Diagnosis of Simple-Virilizing Congenital Adrenal Hyperplasia: A Case Report. Cureus 2022; 14:e29966. [PMID: 36225242 PMCID: PMC9535115 DOI: 10.7759/cureus.29966] [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] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Simple-virilizing congenital adrenal hyperplasia (CAH) is a rare disorder. The objective of this case report is to highlight the challenges in early diagnosis and the treatment of ambiguous genitalia so that a patient can be treated at an early stage and irreversible changes can be prevented. A 13-year-old child, assigned female at birth, presented with the chief complaints of primary amenorrhea. The patient also reported ambiguous genitalia, male pattern hair growth, and deepening of voice (which was progressive and first noted at six years of age). She was evaluated at six years of age but not by an expert. Ultrasound showed a normal uterus and bilateral ovaries, karyotyping XX pattern. On hormonal analysis, serum testosterone and dehydroepiandrosterone sulfate were raised but 17-hydroxyprogesterone (17-OHP) was low; this was against the diagnosis of CAH. As 17-OHP was not raised, we performed a computerized tomography scan, which showed adrenal hyperplasia. A repeat 17-OHP test showed a level of 2,000 ng/dL (>800 ng/dL is diagnostic of CAH). We highlight several challenges in the diagnosis of the simple virilizing form of CAH. The patient’s primary complaint was primary amenorrhea, she herself did not think virilization to be important. Possibly due to social and financial issues, she had not received expert opinion in early childhood. We cannot rely solely on an investigation alone but need to see the patient as a whole. With proper and timely referral and diagnosis, we can limit serious morbidity in the form of virilization as treatments to prevent it are basic.
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Krege S, Falhammar H, Lax H, Roehle R, Claahsen-van der Grinten H, Kortmann B, Duranteau L, Nordenskjöld A. Long-Term Results of Surgical Treatment and Patient-Reported Outcomes in Congenital Adrenal Hyperplasia-A Multicenter European Registry Study. J Clin Med 2022; 11:jcm11154629. [PMID: 35956243 PMCID: PMC9369813 DOI: 10.3390/jcm11154629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Representatives for congenital adrenal hyperplasia (CAH) continue to desire early feminizing surgery in girls with 46,XX-CAH. The aim of this analysis, which included 174 46,XX- individuals with salt-wasting (SW) or simple-virilizing (SV) CAH, a female gender identity, and an age > 16 years participating in a multicenter cross-sectional clinical evaluation study (dsd-LIFE), was to evaluate the long-term results of surgery and patient-reported outcomes (PRO). The gynecological examination (n = 84) revealed some shortcomings concerning surgical feminization. A clitoris was absent in 9.5% of cases, while a clitoral hood was missing in 36.7% of cases. Though all women had large labia, they didn’t look normal in 22.6% of cases. Small labia were absent in 23.8% of cases. There was no introitus vaginae, and the urethra and vagina had no separate opening in 5.1% of cases. A mucosal lining was missing in 15.4% of cases. Furthermore, 86.2% of the women had scars at the region of their external genitalia. A vaginal stenosis was described in 16.5% of cases, and a meatal stenosis was described in 2.6% of cases. Additionally, PRO data showed a very-/high satisfaction rate of 21.3%/40.2% with cosmesis and 23.8%/38.1% with functionality, while 3.3%/10.7% showed a very-/low satisfaction with cosmesis as well as 5.6%/10.3% with functionality. The remaining women—24.6% and 23.8%—were indifferent. Satisfaction concerning sex life was very-/high in 9.6%/27.7%. In 12.0%/16.9% it was very-/low. Furthermore, 33.7% had no opinion. Furthermore, 27.0%/31.6% of the women reported that clitoriplasty, but not clitoridectomy, had a very-/positive influence on their lives, while 1.3%/8.9% felt it to be very-/negative, and 28.4% were indifferent. Vaginoplasty had a very-/positive influence in 25.7%/33.8% and a very-/negative effect in 3.6%/6.8%. 29.7% had no opinion. Additionally, 75.7% of the women preferred feminizing surgery during infancy/childhood, especially concerning clitoreduction. In conclusion, though the majority of the participants (76%) preferred early feminizing surgery and 60% described a positive effect on their lives, about 10% felt it to have been negative. About 15% of the women suffered from insufficient cosmesis and functionality after surgery. Sex life was even described as poor in nearly 30%. Therefore, the decision about early genital surgery in 46,XX-CAH girls should be considered carefully. Parents should get detailed information about possible complications of surgery and should receive support to understand that postponing surgery does not inevitably cause harm for their child. Importantly, genital surgery when performed in children should only be performed in expert centers with a specialized team including surgeons who are trained in feminizing surgery.
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Affiliation(s)
- Susanne Krege
- Department of Urology, Pediatric Urology and Urooncology, Kliniken Essen Mitte, 45136 Essen, Germany
- Correspondence: ; Tel.: +49-201-174-29003; Fax: +49-201-174-29000
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Hildegard Lax
- Institute of Medical Informatics, Biometry and Epidemiology, University of Essen, 45147 Essen, Germany
| | - Robert Roehle
- Institute of Biometry and Clinical Epidemiology, Charite-University Medicine Berlin, 10117 Berlin, Germany
- Institute of Health, Charite-University Medicine Berlin, 10117 Berlin, Germany
| | | | - Barbara Kortmann
- Department of Pediatric Urology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Lise Duranteau
- Department of Medical Gynaecology and Reference Centre for Rare Diseases of Genital Development, Bicetre Hospital, APHP Paris Saclay University, 94270 Le Kremlin Bicetre, France
| | - Agneta Nordenskjöld
- Department of Women’s and Children’s Health, Center of Molecular Medicine, Karolinska Institutet, 17176 Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
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Utari A, Faradz SMH, Ediati A, Rinne T, Ariani MD, Juniarto AZ, Drop SLS, van Herwaarden AE, Claahsen-van der Grinten HL. Challenges in the treatment of late-identified untreated congenital adrenal hyperplasia due to CYP11B1 deficiency: Lessons from a developing country. Front Endocrinol (Lausanne) 2022; 13:1015973. [PMID: 36589846 PMCID: PMC9797803 DOI: 10.3389/fendo.2022.1015973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Congenital Adrenal Hyperplasia (CAH) due to CYP11B1 is a rare autosomal recessive adrenal disorder that causes a decrease in cortisol production and accumulation of adrenal androgens and steroid precursors with mineralocorticoid activity. Clinical manifestations include cortisol deficiency, ambiguous genitalia in females (differences of sex development (DSD)), and hypertension. Medical treatment recommendations are well defined, consisting of glucocorticoid treatment to substitute glucocorticoid deficiency and consequently normalize adrenal androgen and precursors levels. Current guidelines also emphasize the need for specialized multidisciplinary DSD teams and psychosocial support. In many developing countries, care for DSD patients, especially when caused by an adrenal disease, is challenging due to the lack of infrastructure, knowledge, and medication. OBJECTIVE The study aims to report the conflicting decision-making process of medical treatment and sex assignment in late-identified CAH patients in developing countries. METHODS We describe the clinical and biochemical findings and the psychological assessment of five affected but untreated family members with CAH due to CYP11B1 deficiency. RESULTS All patients had a 46,XX karyotype, ambiguous genitalia, low cortisol levels, and hypertension. Two identified as males, two as females, and one had undecided gender. The patients were counselled that refusing treatment will lead to infertility and the potential risk of developing Addisonian crisis and severe hypertension. However, all 46,XX CAH males refused treatment with glucocorticoids due to the expected lowering of adrenal androgens as their main source of testosterone. None of the patients developed Addisonian crisis, probably due to some residual cortisol activity and glucocorticoid activity of elevated adrenal steroid precursors. CONCLUSION Medical treatment and sex assignment in late-identified 46,XX CAH patients in Indonesia may often depend on local and cultural factors. The management of DSD conditions may have to be individualized and integrated into the psychological and social context of the affected family.
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Affiliation(s)
- Agustini Utari
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- *Correspondence: Agustini Utari,
| | - Sultana M. H. Faradz
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Annastasia Ediati
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Faculty of Psychology, Diponegoro University, Semarang, Indonesia
| | - Tuula Rinne
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mahayu Dewi Ariani
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Achmad Zulfa Juniarto
- Center for Biomedical Research (CEBIOR), Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stenvert L. S. Drop
- Division of Pediatric Endocrinology, Sophia Children’s Hospital and Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Hedi L. Claahsen-van der Grinten
- Division of Pediatric Endocrinology, Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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Nonsense variant of NR0B1 causes hormone disorders associated with congenital adrenal hyperplasia. Sci Rep 2021; 11:16066. [PMID: 34373561 PMCID: PMC8352982 DOI: 10.1038/s41598-021-95642-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a rare X-linked recessive inherited disease that is considered a major cause of steroidogenesis disorder and is associated with variants or complete deletion of the NR0B1 gene. The DAX-1 protein (encoded by NR0B1) is a vertebrate-specific orphan nuclear receptor and is also a transcriptional factor for adrenal and reproductive development. CAH usually causes adrenal insufficiency in infancy and early childhood, leading to hypogonadotropic hypogonadism in adulthood; however, few adult cases have been reported to date. In this study, we examined a Chinese family with one adult patient with CAH, and identified a putative variant of NR0B1 gene via next-generation sequencing (NGS), which was confirmed with Sanger sequencing. A novel nonsense variant (c.265C>T) was identified in the NR0B1 gene, which caused the premature termination of DAX-1 at residue 89 (p.G89*). Furthermore, mutant NR0B1 gene displayed a partial DAX-1 function, which may explain the late pathogenesis in our case. Additionally, qPCR revealed the abnormal expression of four important genes identified from ChIP-seq, which were associated with energy homeostasis and steroidogenesis, and were influenced by the DAX-1 mutant. In addition, hormone disorders can be caused by DAX-1 mutant and partially recovered by siRNA of PPARGC1A. Herein, we identified a novel nonsense variant (c.265C>T) of NR0B1 in a 24-year-old Chinese male who was suffering from CAH. This mutant DAX-1 protein was found to have disordered energy homeostasis and steroidogenesis based on in vitro studies, which was clinically consistent with the patient’s phenotypic features.
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de Almeida RB, Apóstolos RAC, Oliveira LMB, Toralles MBP, Lago RMRS, Faria JAD, Arruti RA, Rodrigues MLB, Amorim T, Dos Santos HMGP, de Sousa LA, Barroso U. Is there an association between prostate-specific antigen and androgen levels in 46, XX patients with congenital adrenal hyperplasia? J Pediatr Urol 2021; 17:481.e1-481.e7. [PMID: 34092513 DOI: 10.1016/j.jpurol.2021.05.003] [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: 06/24/2020] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Congenital adrenal hyperplasia (CAH), a genetic disease characterized by defective cortisol synthesis and excessive levels of sex hormones, can cause precocious puberty in both sexes in untreated individuals and virilization in female patients with a 46, XX karyotype. The female paraurethral (Skene's) gland has been reported as prostate analogous. Growth of prostate tissue is associated with androgen production; therefore, prostate-specific antigen (PSA) levels may represent a marker of virilization in 46, XX patients with CAH. OBJECTIVES To describe PSA levels in 46, XX patients and evaluate whether higher PSA levels are associated with androgenization and the severity of the disease. STUDY DESIGN Sixty-six patients with CAH and a 46, XX karyotype were included, irrespective of age. Serum PSA, testosterone, 17-hydroxyprogesterone (17-OHP) and androstenedione levels were measured. Patients' age, age at diagnosis, forms of the disease, Prader classification, bone age assessment, sex of rearing, surgery, and the presence of clinical complications were obtained from their medical records. RESULTS The mean age of patients was 11.45 ± 10.74 years. Forty-three patients (65%) were diagnosed neonatally at a median of 0.08 years (mean 1.47 ± 2.34 years), with registers of 17-OHP measurements (Guthrie test) being available in 51%. Testosterone, 17-OHP and androstenedione were significantly high. PSA was detectable in 25% of cases (levels >0.01 ng/ml), with a mean of 0.03 ± 0.09 ng/ml, and only in patients over five years of age. A correlation was found between PSA and age (p < 0.001), age at diagnosis (p = 0.002), testosterone (p = 0.001) and androstenedione (p = 0.023). There was no correlation between PSA and the forms of CAH or Prader classification. A sub-analysis of the patients over five years of age in whom PSA was detectable also showed that there was a correlation between PSA (p < 0.05) and age at analysis, age at diagnosis, testosterone and androstenedione levels. DISCUSSION Limitations of this study include the small sample size due to the rareness of the disease, its retrospective nature, the absence of a control group, the fact that the sample was selected at two referral centers, which could have resulted in a selection bias, and the use of different reference values in the different laboratories conducting the PSA tests. CONCLUSIONS PSA is detectable in 25% of 46, XX patients with CAH, only after five years of age. PSA level increases significantly with age, age at diagnosis, and testosterone and androstenedione levels, confirming a correlation between PSA levels and elevated androgen levels.
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Affiliation(s)
| | | | | | | | - Renata Maria R S Lago
- Multidisciplinary Clinic for Disorders of Sexual Development, Federal University of Bahia, Salvador, Bahia, Brazil
| | - José Antonio Diniz Faria
- Multidisciplinary Clinic for Disorders of Sexual Development, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Renata Andion Arruti
- The Salvador Association of Parents and Friends of Individuals with Special Needs (APAE), Salvador, Bahia, Brazil
| | | | - Tatiana Amorim
- The Salvador Association of Parents and Friends of Individuals with Special Needs (APAE), Salvador, Bahia, Brazil
| | | | | | - Ubirajara Barroso
- Multidisciplinary Clinic for Disorders of Sexual Development, Federal University of Bahia, Salvador, Bahia, Brazil.
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Savaş-Erdeve Ş, Aycan Z, Çetinkaya S, Öztürk AP, Baş F, Poyrazoğlu Ş, Darendeliler F, Özsu E, Şıklar Z, Demiral M, Unal E, Özbek MN, Gürbüz F, Yüksel B, Evliyaoğlu O, Akyürek N, Berberoğlu M. Clinical Characteristics of 46,XX Males with Congenital Adrenal Hyperplasia. J Clin Res Pediatr Endocrinol 2021; 13:180-186. [PMID: 33374095 PMCID: PMC8186342 DOI: 10.4274/jcrpe.galenos.2020.2020.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To retrospectively evaluate the follow-up data in patients with 46,XX congenital adrenal hyperplasia (CAH) who were raised male. METHODS A national database was created. The data of patients were asked to be recorded in the data form. RESULTS The median (range) age of diagnosis was three (0.1-18.3) years in 44 patients. Twenty nine cases were diagnosed after the age of two years. Most (95.4%) cases were stage 4-5 virilized. Hysterectomy and bilateral salpingoopherectomy, at a median age of 7.25 (2.4-25.3) years, was performed in 35 cases. Testicular prostheses were placed in 11 (25%) cases at a median age of 11.2 (2.8-17) years. The median final height was 149.2 (132.8-172) cms in 38 patients, including simple virilizing (n=18), salt-wasting (n=6), and 11-beta hydroxylase (n=12). Of the 16 patients above the age of eighteen, university education was completed in 25%. CONCLUSION It was seen that most (65.9%) of the 46,XX CAH cases raised male were diagnosed after two years of age. In these cases, hysterectomy and bilateral salpingoopherectomy, genital corrective surgeries and testicular prosthesis operations were performed in a very wide age rage.
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Affiliation(s)
- Şenay Savaş-Erdeve
- University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey,* Address for Correspondence: University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey E-mail:
| | - Zehra Aycan
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Semra Çetinkaya
- University of Health Sciences Turkey, Dr. Sami Ulus Obstetrics and Gynecology, Children’s Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Ayşe Pınar Öztürk
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Firdevs Baş
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Şükran Poyrazoğlu
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Feyza Darendeliler
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Elif Özsu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Meliha Demiral
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Edip Unal
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Mehmet Nuri Özbek
- University of Health Sciences Turkey, Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Bilgin Yüksel
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Olcay Evliyaoğlu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Nesibe Akyürek
- University of Health Sciences Turkey, Konya Training and Research Hospital, Clinic of Pediatric Endocrinology, Konya, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Nikitina I, Kudryashova E, Kelmanson I. Prenatal androgen exposure and gender behavior in disorders of sex development. SEXOLOGIES 2021. [DOI: 10.1016/j.sexol.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gürbüz F, Alkan M, Çelik G, Bişgin A, Çekin N, Ünal İ, Topaloğlu AK, Zorludemir Ü, Avcı A, Yüksel B. Gender Identity and Assignment Recommendations in Disorders of Sex Development Patients: 20 Years’ Experience and Challenges. J Clin Res Pediatr Endocrinol 2020; 12:347-357. [PMID: 32212580 PMCID: PMC7711639 DOI: 10.4274/jcrpe.galenos.2020.2020.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Gender assignment in infants and children with disorders of sex development (DSD) is a stressful situation for both patient/families and medical professionals. METHODS The purpose of this study was to investigate the results of gender assignment recommendations in children with DSD in our clinic from 1999 through 2019. RESULTS The mean age of the 226 patients with DSD at the time of first admission were 3.05±4.70 years. 50.9% of patients were 46,XY DSD, 42.9% were 46,XX DSD and 6.2% were sex chromosome DSD. Congenital adrenal hyperplasia (majority of patients had 21-hydroxylase deficiency) was the most common etiological cause of 46,XX DSD. In 46,XX patients, 87 of 99 (89.7%) were recommended to be supported as a female, 6 as a male, and 4 were followed up. In 46,XY patients, 40 of 115 (34.8%) were recommended to be supported as a female, and 70 as male (60.9%), and 5 were followed up. In sex chromosome DSD patients, 3 of 14 were recommended to be supported as a female, 9 as a male. The greatest difficulty in making gender assignment recommendations were in the 46,XY DSD group. CONCLUSION In DSD gender assignment recommendations, the etiologic diagnosis, psychiatric gender orientation, expectation of the family, phallus length and Prader stage were effective in the gender assignment in DSD cases, especially the first two criteria. It is important to share these experiences among the medical professionals who are routinely charged with this difficult task in multidisciplinary councils.
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Affiliation(s)
- Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Murat Alkan
- Çukurova University Faculty of Medicine, Department of Pediatric Surgery, Adana, Turkey
| | - Gonca Çelik
- Çukurova University Faculty of Medicine, Department of Child Psychiatry, Adana, Turkey
| | - Atıl Bişgin
- Çukurova University Faculty of Medicine, Department of Medical Genetics, Adana, Turkey
| | - Necmi Çekin
- Çukurova University Faculty of Medicine, Department of Forensic Medicine, Adana, Turkey
| | - İlker Ünal
- Çukurova University Faculty of Medicine, Department of Biostatistics, Adana, Turkey
| | - Ali Kemal Topaloğlu
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Ünal Zorludemir
- Çukurova University Faculty of Medicine, Department of Pediatric Surgery, Adana, Turkey
| | - Ayşe Avcı
- Çukurova University Faculty of Medicine, Department of Child Psychiatry, Adana, Turkey
| | - Bilgin Yüksel
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey,* Address for Correspondence: Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey Phone: +90 532 516 91 31 E-mail:
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Bangalore Krishna K, Kogan BA, Ernst MM, Romao RL, Mohsin F, Serrano-Gonzalez M, Quintos JB, Phornphutkul C, Aguiar L, Lee PA. Individualized care for patients with intersex (disorders/differences of sex development): Part 3. J Pediatr Urol 2020; 16:598-605. [PMID: 32605872 DOI: 10.1016/j.jpurol.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment. We recommend an individualized approach by a multidisciplinary team utilizing a range of evolving strategies, including outcome data (or lack thereof) to support families during the decision-making process.
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Affiliation(s)
| | | | - Michelle M Ernst
- University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | | | | | | | | | - Chanika Phornphutkul
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Liza Aguiar
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA
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11
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Shiryaev ND, Kagantsov IM, Sizonov VV. [Disorders of sex differentiation: state of the problem 15 years after the Chicago consensus]. PROBLEMY ENDOKRINOLOGII 2020; 66:70-80. [PMID: 33351341 DOI: 10.14341/probl12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 06/12/2023]
Abstract
It is well known that the nomenclature and classification were changed in 2005 at the international consensus conference on intersex disorders, held in Chicago, where, among others, the following recommendations were proposed: (1) all children should be assigned a gender identity, and this should be done as quickly as possible, taking into account the time required for the examination. (2) all infants with congenital adrenal hyperplasia and 46,XX karyotype, including those with pronounced masculinization, must be raised as women. (3) Surgical treatment should be performed early and in cases of feminizing genitoplasty, clitoral reduction should be performed simultaneously with reconstruction of the urogenital sinus (separation of the vagina and urethra). An analysis of contemporary literature shows that all these theories, proposed 15 years ago at the Chicago meeting, failed to stand the test of time. New nomenclature and classification are constantly being revised. Currently, many groups of patients want to abolish the term «sexual maturity disorders.» Recommendations regarding gender reassignment and appropriate early surgical treatment have been completely ignored in some countries. All this was largely facilitated by the confrontational activities of a number of support groups.
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Affiliation(s)
| | - Ilya M Kagantsov
- Pitirim Sorokin Syktyvkar State University; Republican Children's Clinical Hospital
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12
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Lim E, Jeon JY. Congenital adrenal hyperplasia presenting as pelvic inflammatory disease in a phenotypic male: A case report. Medicine (Baltimore) 2020; 99:e18387. [PMID: 31914016 PMCID: PMC6959940 DOI: 10.1097/md.0000000000018387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Congenital adrenal hyperplasia (CAH) is caused by various enzyme deficiencies, among which 21-hydroxylase (21-OH) deficiency accounts for more than 90% of cases. Neonatal screening became mandatory only a few decades ago. Many patients who were born before this went undiagnosed and some of the severely virilized females were raised as men. PATIENT CONCERNS A 58-year old man with a history of excisional surgery in the external genitalia when he was a toddler presented with three days of dysuria and low abdominal pain. DIAGNOSIS The patient's laboratory results showed leukocytosis and elevated C-reactive protein (CRP); thus, the physicians decided to perform a computed tomography (CT) scan. The CT demonstrated pelvic inflammatory disease (PID), left adrenal gland myelolipoma, and a mesenteric mass. Meanwhile, we suspected CAH based on the clinical history and assessed the patient's hormone levels. Seventeen-hydroxyprogesterone (17-OH-PG) was markedly elevated and the patient was diagnosed with classic simple virilizing CAH. INTERVENTIONS Intravenous antibiotics were administered, and positron emission tomography-CT (PET-CT) was performed to evaluate any metastases. OUTCOMES After 2 weeks of antibiotic treatment, CRP decreased to 0.12 mg/dL and PID was resolved. The patient opted for resection of the female genitalia along with the mesenteric and adrenal gland tumors in the near future, and was safely discharged. LESSONS The adrenal gland myelolipoma was thought to have developed as a result of a longstanding exposure to adrenocorticotropic hormone. There are controversies regarding the management of female genitalia in CAH patients who identify themselves as men. In this case, the physician and patient decided to remove the female genitalia because the surgery for the mesenteric mass was inevitable and there was a possibility of recurrent PID. To our knowledge, this is the first article to report primary mesenteric tumor in a CAH patient to date. In conclusion, patients who were born before neonatal screening for CAH became the mainstay, who are suspected to have CAH from their history, and present with abdominal pain must be diagnosed by performing an imaging study, testing levels of serum 17-OH-PG, and screening for female genitalia and adrenal gland myelolipoma.
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Affiliation(s)
- Eunsoo Lim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
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Miranda MCD, Haddad LBDP, Madureira G, Mendonca BBD, Bachega TASS. Adverse Outcomes and Economic Burden of Congenital Adrenal Hyperplasia Late Diagnosis in the Newborn Screening Absence. J Endocr Soc 2019; 4:bvz013. [PMID: 32047870 PMCID: PMC7003980 DOI: 10.1210/jendso/bvz013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/15/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To establish short- and long-term adverse outcome frequencies related to a late diagnosis of congenital adrenal hyperplasia (CAH) in the absence of newborn screening (NBS) and to determine respective treatment costs, which have never been reported. Design A retrospective analysis of a CAH cohort diagnosed without NBS. Methods We evaluated medical record data concerning 195 patients (141 females) diagnosed with CAH through clinical suspicion and confirmed using hormonal and CYP21A2 analysis, who were followed from 1980 to 2016 at Sao Paulo University. We measured mortality, dehydration, mental impairment frequencies, and hospitalization length outcomes in the salt-wasting form; the frequency of genetic females raised as males in both forms, frequency of depot GnRh analog (GnRha) and GH therapies in the simple virilizing form, and related outcome costs were calculated. Results Mortality rates and associated costs, varying from 10% to 26% and from $2,239,744.76 to $10,271,591.25, respectively, were calculated using the Brazilian yearly live-births rate, estimated productive life years, and gross domestic product. In the salt-wasting form, 76% of patients were hospitalized, 8.6% were mentally impaired, and 3% of females were raised as males (total cost, $86,230/salt-wasting patient). GnRha and growth hormone were used for 28% and 14% of simple virilizing patients, respectively, and 18% of females were raised as males (preventable cost, $4232.74/simple virilizing patient). Conclusions A late CAH diagnosis leads to high mortality and morbidity rates, notably increasing public health costs, and may result in physical and psychological damage that is not easily measurable.
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Affiliation(s)
- Mirela Costa De Miranda
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciana Bertocco De Paiva Haddad
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Guiomar Madureira
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice Bilharinho De Mendonca
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Tania A S S Bachega
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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de Jesus LE, Costa EC, Dekermacher S. Gender dysphoria and XX congenital adrenal hyperplasia: how frequent is it? Is male-sex rearing a good idea? J Pediatr Surg 2019; 54:2421-2427. [PMID: 30905417 DOI: 10.1016/j.jpedsurg.2019.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/26/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The frequency of gender dysphoria (GD) among 46,XX congenital adrenal hyperplasia (CAH) patients is unknown. These data are needed to put into perspective the debate about the timing of reconstructive surgery and possible male-raising of the most severely virilized children. OBJECTIVE To analyze the frequency of female to male GD between 46,XX individuals raised as females; to identify subgroups with higher chances of showing GD; to describe the results of male-raising among 46,XX CAH patients. MATERIALS AND METHODS Analytic/descriptive literature review (January 1988 to April 2018). RESULTS Female-raised patients frequently report the desire to be male, adopt male-typical behavior and are frequently homosexual/bisexual as adults, but this does not correspond to GD. Declared GD among 46,XX CAH patients attained 9% of the reported cohorts, generally in late adolescence/adulthood. We could not prove a relationship between inadequate treatment, null-genotype, late diagnoses, a higher degree of virilization, type of CAH or higher levels of androgens and female to male GD, but this may be due to statistical limitations. Male gender raised patients (MGR) were 10.1% of CAH cohorts included in this review, mostly from underdeveloped countries, with a high proportion of late diagnoses (76.3%) and familial choices. GD was more common in this group than among female-raised patients. Opting for male gender relates to a short final height, the need for multiple surgeries, surgical castration before puberty and infertility. CONCLUSION Both male to female and female to male GD may present in 46,XX CAH patients in a contemporaneous cohort. The proportion of GD is higher among patients raised as males. DSD patients sexual maladjustments are complex and not comparable to the transgender population. Many 46,XX CAH patients with GD define themselves as gender-fluid and do not seek for legal/formal transition. Male-raising Prader 4/5 46,XX CAH patients imply infertility and multiple surgeries. There is no proof that any subgroup of CAH is more prone to GD, despite null genotypes, salt wasting phenotypes and Prader 4/5 cases being related to male-typical behavior and female homosexuality. TYPE OF STUDY Descriptive/analytic non-systematic REVIEW. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lisieux Eyer de Jesus
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil; Pediatric Surgery and Urology Department, Antonio Pedro University Hospital, UFF, Rio de Janeiro, Brazil.
| | - Eduardo Corrêa Costa
- Pediatric Surgery and Urology Department, Porto Alegre Clinics Hospital, UFRS, Porto Alegre, Brazil
| | - Samuel Dekermacher
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil
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Kim HJ. Response to Apóstolos et al.'s (2018) "Gender Identity and Sexual Function in 46,XX Patients with Congenital Adrenal Hyperplasia Raised as Males". ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:675-677. [PMID: 30659438 DOI: 10.1007/s10508-018-1386-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/19/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Hee Jin Kim
- Department of Internal Medicine, Dankook University College of Medicine, 119, Dandae-ro, Dongnam-gu, Cheonan-si, Chungnam, 31116, Republic of Korea.
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Suchartlikitwong S, Jasti R, Lado-Abeal J, Rivas Mejia AM. Bilateral adrenal myelolipomas presenting as acute adrenal insufficiency in an adult with congenital adrenal hyperplasia. BMJ Case Rep 2019; 12:12/2/bcr-2018-226826. [PMID: 30739087 DOI: 10.1136/bcr-2018-226826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Adrenal myelolipomas are relatively rare tumours composed of adipocytes and myeloid cells that arise in response to chronic adrenocorticotropic hormone stimulation. We present the case of bilateral adrenal myelolipomas in a 39-year-old man with untreated congenital adrenal hyperplasia (CAH) presenting with acute adrenal insufficiency and severe virilisation. Phenotypically, he is a man of short stature and has hyperpigmentation of the skin, gingiva and nail beds. Genital examination revealed micropenis and no palpable testes. Laboratory testing was consistent with primary adrenal insufficiency. An abdominal CT showed bilateral adrenal myelolipomas. An MRI of the pelvis revealed female reproductive organs. Chromosome study showed a karyotype of 46,XX. A CYP21A2 gene mutation confirmed diagnosis of CAH with 21-hydroxylase deficiency. The patient was treated with stress dose corticosteroids, subsequently tapered to physiological doses. We review previously reported cases and discussed diagnosis and treatment, including hormonal therapy and psychological approach.
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Affiliation(s)
| | - Rahul Jasti
- Radiology, Texas Tech University Health Sciences Centre, Lubbock, Texas, USA
| | - Joaquin Lado-Abeal
- Department of Internal Medicine, division of Endocrinology, Texas Tech University Health Sciences Centre School of Medicine, Lubbock, Texas, USA
| | - Ana Marcella Rivas Mejia
- Department of Internal Medicine, division of Endocrinology, Texas Tech University Health Sciences Centre School of Medicine, Lubbock, Texas, USA
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Apóstolos RAC, Canguçu-Campinho AK, Lago R, Costa ACS, Oliveira LMB, Toralles MB, Barroso U. Gender Identity and Sexual Function in 46,XX Patients with Congenital Adrenal Hyperplasia Raised as Males. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:2491-2496. [PMID: 30291599 DOI: 10.1007/s10508-018-1299-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 06/08/2023]
Abstract
In individuals with congenital adrenal hyperplasia (CAH) and 46,XX karyotype, androgens produced by the adrenal glands during the intrauterine development promote virilization of the genitals, which may even result in the development of a well-formed penis. Some of these children with late diagnosis are registered as males after birth. After obtaining approval from the internal review board, we evaluated gender identity and sexual function in four 46,XX severely virilized patients with CAH, who were originally registered and raised as males, assisted in our Disorders of Sexual Development Clinic. The evaluation consisted of questionnaires to assess gender identity and sexual activity and interview with the multidisciplinary team that provides care for these patients. The patients underwent surgery to remove uterus, ovaries, and remaining vaginal structures, in addition to implantation of testicular prosthesis and correction of hypospadias, when necessary. All four patients have developed a clear male gender identity, and when evaluated for sexual activity, they have reported having erections, libido, orgasms, and sexual attraction to women only. Two of these 4 patients had satisfactory sexual intercourses when assessed using the International Index of Erectile Function questionnaire. The other two patients who never had sexual intercourse reported not having a partner for sexual activity; one is 18 years old, and the other is 14 years old. This study showed that this group of 46,XX severely virilized patients with CAH, registered and raised as males, adapted well to the assigned male gender, with satisfactory sexual function in patients who had sexual intercourse.
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Affiliation(s)
- Robson A C Apóstolos
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Ana Karina Canguçu-Campinho
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Renata Lago
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | | | - Luciana M B Oliveira
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Maria Betania Toralles
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil
| | - Ubirajara Barroso
- Disorders of Sexual Development Clinic, Federal University of Bahia, Av Alphaville 1, Rua Pajuçara, 335, Salvador, Bahia, 41701015, Brazil.
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil.
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Kim S, Rosoklija I, Johnson EK. Surgical, Patient, and Parental Considerations in the Management of Children with Differences of Sex Development. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kreukels BPC, Köhler B, Nordenström A, Roehle R, Thyen U, Bouvattier C, de Vries ALC, Cohen-Kettenis PT. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018; 15:777-785. [PMID: 29606626 DOI: 10.1016/j.jsxm.2018.02.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Information on the psychosexual outcome of individuals with disorders of sex development (DSDs) and intersex conditions is of great importance for sex assignment at birth of newborns with DSD. AIM To assess gender change and gender dysphoria in a large sample of individuals with different DSDs. METHODS A cross-sectional study was conducted in 14 European centers with 1,040 participants (717 female-identifying and 311 male-identifying persons and 12 persons identifying with another gender) with different forms of DSD. The cohort (mean age = 32.36 years, SD = 13.57) was divided into 6 major subgroups: women with 45,X DSD and variants (Turner syndrome; n = 325), men with 47,XXY DSD and variants (Klinefelter syndrome; n = 219), women with XY DSD without androgen effects (n = 107) and with androgen effects (n = 63), men with XY DSD (n = 87), and women with 46,XX congenital adrenal hyperplasia (n = 221). Data on psychosexual outcome were gathered by medical interviews and questionnaires. OUTCOMES Gender change and gender dysphoria. RESULTS Although gender changes were reported by 5% of participants, only in 1% (3% if those with Klinefelter and Turner syndromes-conditions in which gender issues are not prominent-are excluded) did the gender change take place after puberty and was likely initiated by the patient. 39 participants (4%) reported gender variance: between male and female, a gender other than male or female, or gender queer, alternating gender roles, or a gender expression that differed from the reported gender. This group had lower self-esteem and more anxiety and depression than the other participants. CLINICAL IMPLICATIONS Clinicians should be aware of and sensitive to the possibility that their patients with DSD not only might have transgender feelings and a desire to change gender, but also identify as different from male or female. The complexity of their feelings might require counseling for some patients. STRENGTHS AND LIMITATIONS The study is unique in the large number of participants from many different clinics, with sizable numbers in most subgroups, and in the large number of aspects that were measured. However, the very broadness of the study made it impossible to focus in detail on gender issues. Also, there is a need for instruments specifically measuring gender dysphoria in individuals with DSD that take non-binary genders into account. CONCLUSION To make appropriate gender care possible for people with DSD, the gender-normative and gender-variant development of children with DSD should be studied in longitudinal studies. Kreukels BPC, Köhler B, Nordenström A, et al. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018;15:777-785.
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Affiliation(s)
- Baudewijntje P C Kreukels
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - Birgit Köhler
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie CVK, Charité Universitätsmedizin, Berlin, Germany
| | - Anna Nordenström
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Robert Roehle
- Koordinierungszentrum Klinische Studien (KKS), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin Universität zu Lübeck, Lübeck, Germany
| | - Claire Bouvattier
- Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Paris Sud University, Paris, France
| | - Annelou L C de Vries
- Department of Child Psychiatry, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
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Abstract
The congenital adrenal hyperplasias comprise a family of autosomal recessive disorders that disrupt adrenal steroidogenesis. The most common form is due to 21-hydroxylase deficiency associated with mutations in the 21-hydroxylase gene, which is located at chromosome 6p21. The clinical features associated with each disorder of adrenal steroidogenesis represent a clinical spectrum that reflect the consequences of the specific mutations. Treatment goals include normal linear growth velocity and "on-time" puberty in affected children. For adolescent and adult women, treatment goals include regularization of menses, prevention of progression of hirsutism, and preservation of fertility. For adolescent and adult men, prevention and early treatment of testicular adrenal rest tumors is beneficial. In this article key aspects regarding pathophysiology, diagnosis, and treatment of congenital adrenal hyperplasia are reviewed.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania.
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21
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Bakula DM, Mullins AJ, Sharkey CM, Wolfe-Christensen C, Mullins LL, Wisniewski AB. Gender identity outcomes in children with disorders/differences of sex development: Predictive factors. Semin Perinatol 2017; 41:214-217. [PMID: 28478086 DOI: 10.1053/j.semperi.2017.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disorders/differences of sex development (DSD) comprise multiple congenital conditions in which chromosomal, gonadal, and/or anatomical sex are discordant. The prediction of future gender identity (i.e., self-identifying as male, female, or other) in children with DSD can be imprecise, and current knowledge about the development of gender identity in people with, and without DSD, is limited. However, sex of rearing is the strongest predictor of gender identity for the majority of individuals with various DSD conditions. When making decisions regarding sex of rearing biological factors (e.g., possession of a Y chromosome, degree and duration of pre- and postnatal androgen exposure, phenotypic presentation of the external genitalia, and fertility potential), social and cultural factors, as well as quality of life should be considered. Information on gender identity outcomes across a range of DSD diagnoses is presented to aid in sex of rearing assignment.
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Affiliation(s)
- Dana M Bakula
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074.
| | - Alexandria J Mullins
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | - Christina M Sharkey
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | | | - Larry L Mullins
- Department of Psychology, Oklahoma State University, 305 North Murray Hall, Stillwater, OK 74074
| | - Amy B Wisniewski
- Department of Pediatric Urology, Genitourinary Program, Cook Children's Hospital, Fort Worth, TX
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