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Planinic A, Maric T, Himelreich Peric M, Jezek D, Katusic Bojanac A. Dynamics of HSD17B3 expression in human fetal testis: implications for the role of Sertoli cells in fetal testosterone biosynthesis. Front Cell Dev Biol 2024; 12:1429292. [PMID: 39139451 PMCID: PMC11319120 DOI: 10.3389/fcell.2024.1429292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction: Androgens play a pivotal role in shaping male sexual characteristics, with testosterone being an essential hormone in orchestrating various developmental processes. Testosterone biosynthesis involves a series of enzymatic reactions, among which the 17β-hydroxysteroid dehydrogenase type 3 (HSD17B3) holds significance. While its role in adult Leydig cells is well established, its localization and importance during the fetal period remain less known, especially in humans. This study aims to delineate the dynamics of HSD17B3 expression in human fetal testes to clarify the contribution of specific cell types to testosterone biosynthesis. Methods: Using immunofluorescence staining, we investigated the expression pattern of HSD17B3 in human fetal and adult testicular tissues. Results and discussion: The findings of this study revealed a distinct temporal and cellular expression pattern of HSD17B3 protein in the fetal period. We detected its expression exclusively in Sertoli cells, the highest during the second trimester. This unique localization suggests the inclusion of fetal Sertoli cells in testosterone production during the critical masculinization-programming window. Furthermore, we demonstrated a shift in HSD17B3 expression from Sertoli cells to Leydig cells in adulthood, corroborating findings from rodent studies. This study sheds light on the intricate, still underexplored regulation of steroidogenesis during fetal development, whose disturbance might lead to testicular dysgenesis. Further research is warranted to elucidate the regulatory pathways governing the expression of HSD17B3 and its transition between Sertoli and Leydig cells, potentially paving the way for novel therapeutic interventions in disorders of sexual development.
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Affiliation(s)
- Ana Planinic
- Department of Histology and Embryology, University of Zagreb School of Medicine, Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tihana Maric
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Marta Himelreich Peric
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Davor Jezek
- Department of Histology and Embryology, University of Zagreb School of Medicine, Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ana Katusic Bojanac
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
- Department of Medical Biology, University of Zagreb School of Medicine, Zagreb, Croatia
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2
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Anastasiadou K, Silva M, Booth T, Speidel L, Audsley T, Barrington C, Buckberry J, Fernandes D, Ford B, Gibson M, Gilardet A, Glocke I, Keefe K, Kelly M, Masters M, McCabe J, McIntyre L, Ponce P, Rowland S, Ruiz Ventura J, Swali P, Tait F, Walker D, Webb H, Williams M, Witkin A, Holst M, Loe L, Armit I, Schulting R, Skoglund P. Detection of chromosomal aneuploidy in ancient genomes. Commun Biol 2024; 7:14. [PMID: 38212558 PMCID: PMC10784527 DOI: 10.1038/s42003-023-05642-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024] Open
Abstract
Ancient DNA is a valuable tool for investigating genetic and evolutionary history that can also provide detailed profiles of the lives of ancient individuals. In this study, we develop a generalised computational approach to detect aneuploidies (atypical autosomal and sex chromosome karyotypes) in the ancient genetic record and distinguish such karyotypes from contamination. We confirm that aneuploidies can be detected even in low-coverage genomes ( ~ 0.0001-fold), common in ancient DNA. We apply this method to ancient skeletal remains from Britain to document the first instance of mosaic Turner syndrome (45,X0/46,XX) in the ancient genetic record in an Iron Age individual sequenced to average 9-fold coverage, the earliest known incidence of an individual with a 47,XYY karyotype from the Early Medieval period, as well as individuals with Klinefelter (47,XXY) and Down syndrome (47,XY, + 21). Overall, our approach provides an accessible and automated framework allowing for the detection of individuals with aneuploidies, which extends previous binary approaches. This tool can facilitate the interpretation of burial context and living conditions, as well as elucidate past perceptions of biological sex and people with diverse biological traits.
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Affiliation(s)
- Kyriaki Anastasiadou
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom.
| | - Marina Silva
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Thomas Booth
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Leo Speidel
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
- Genetics Institute, University College London, London, United Kingdom
| | | | - Christopher Barrington
- Bioinformatics and Biostatistics Science Technology Platform, The Francis Crick Institute, London, United Kingdom
| | - Jo Buckberry
- School of Archaeological and Forensic Sciences, University of Bradford, Bradford, United Kingdom
| | | | - Ben Ford
- Oxford Archaeology, Oxford, United Kingdom
| | | | - Alexandre Gilardet
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Isabelle Glocke
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Keefe
- York Osteoarchaeology, York, United Kingdom
- On-Site Archaeology, York, United Kingdom
| | - Monica Kelly
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Mackenzie Masters
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Jesse McCabe
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Paola Ponce
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | | | - Jordi Ruiz Ventura
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Pooja Swali
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | - Frankie Tait
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Helen Webb
- Oxford Archaeology, Oxford, United Kingdom
| | - Mia Williams
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom
| | | | - Malin Holst
- York Osteoarchaeology, York, United Kingdom
- Department of Archaeology, University of York, York, United Kingdom
| | - Louise Loe
- Oxford Archaeology, Oxford, United Kingdom
| | - Ian Armit
- Department of Archaeology, University of York, York, United Kingdom
| | - Rick Schulting
- School of Archaeology, University of Oxford, Oxford, United Kingdom
| | - Pontus Skoglund
- Ancient genomics laboratory, The Francis Crick Institute, London, United Kingdom.
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3
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Johnstone T, Thawanyarat K, Eggert GR, Navarro Y, Rowley MA, Lane M, Darrach H, Nazerali R, Morrison SD. Travel distance and national access to gender-affirming surgery. Surgery 2023; 174:1376-1383. [PMID: 37839968 DOI: 10.1016/j.surg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location. METHODS Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery. RESULTS Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014. CONCLUSION Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.
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Affiliation(s)
| | - Kometh Thawanyarat
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA. http://www.twitter.com/tonythawanyarat
| | - Gina R Eggert
- Department of Molecular, Cellular, and Developmental Biology, University of California Santa Cruz, Santa Cruz, CA
| | - Yelissa Navarro
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA
| | - Mallory A Rowley
- State University of New York, Upstate Medical University, Syracuse, NY
| | - Megan Lane
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Halley Darrach
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Rahim Nazerali
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Shane D Morrison
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Washington, Seattle, WA
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Sex Chromosome Rearrangement Associated With Hormonal Abnormalities and Gender Dysphoria. J Psychiatr Pract 2023; 29:71-76. [PMID: 36649555 DOI: 10.1097/pra.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although disorders arising from sex chromosome and sex steroid abnormalities are well characterized from the perspectives of endocrinology, dysmorphology, and reproductive health, relatively little is known about neuropsychiatric development, gender identity, incongruence, and dysphoria in the populations with these disorders. In this report, we describe the case of a 21-year-old gender nonbinary individual identified as male at birth who presented to an academic psychiatry consultation clinic because of life-long gender dysphoria. The patient was found to have a complex sex chromosomal rearrangement and associated hormonal abnormalities that may, at least in part, explain the patient's history. In addition to describing a novel genetic change, this case and the accompanying review of the existing literature highlight the need for an increased focus on the psychiatric perspective, and sex and gender issues in particular, among all patients with sex chromosome abnormalities and inborn errors of steroid metabolism.
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Ehua AM, Moulot MO, Agbara KS, Enache T, Bankole SR. Disorders of sex development: Challenges in a low-resource country. Arch Pediatr 2023; 30:10-13. [PMID: 36462990 DOI: 10.1016/j.arcped.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 06/15/2022] [Accepted: 09/24/2022] [Indexed: 12/05/2022]
Abstract
AIM We aimed to identify the challenges in the management of sexual development abnormalities in a low-resource country. METHODS The study was retrospective from January 2000 to December 2017 based on patient records from two pediatric surgery departments. Epidemiological, clinical, paraclinical, treatment, and outcome data were studied. RESULTS We collected data on 13 patients (average age = 7.95 years). The sex of rearing was as follows: three females (23%), 10 males (77%). Atypical genitalia other than hypospadias represented the reason for consultation in 92% of the cases. We could not find complete hormonal analyses; testosterone levels were studied in 69.23% of cases. We found the following disorders of sexual development (DSD): four patients with 46,XX karyotype (30.77%), eight patients with 46,XY karyotype (61.53%), and one patient with 46,XX/XY karyotype. Four patients had medical treatment only, four had surgical treatment only, and one patient had medical and surgical treatment. The medical treatment comprised topical administration of androgen. The surgical treatment consisted of feminizing genitoplasty for one patient and masculinizing genital surgeries for two patients. Six of the 13 patients were lost to follow-up. CONCLUSION The socioeconomic difficulties of the population and the lack of access to basic diagnostic and paraclinical methods, coupled with the negative cultural representations of the pathology, constitute the challenges in the management of DSD in our practice.
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Affiliation(s)
- A M Ehua
- Department of Pediatric Surgery Treichville Teaching Hospital Abidjan, Côte d'Ivoire 01 BP V 03 Abidjan 01.
| | - M O Moulot
- Department of Pediatric Surgery Treichville Teaching Hospital Abidjan, Côte d'Ivoire 01 BP V 03 Abidjan 01
| | - K S Agbara
- Department of Pediatric Surgery Treichville Teaching Hospital Abidjan, Côte d'Ivoire 01 BP V 03 Abidjan 01
| | - T Enache
- Clinical Emergency Hospital for Children, Grigore Alexandrescu Bucharest, Romania
| | - S R Bankole
- Department of Pediatric Surgery Treichville Teaching Hospital Abidjan, Côte d'Ivoire 01 BP V 03 Abidjan 01
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6
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Bridi Filho CA, Cardoso SB, Soll BMB, Noal MF, Schwarz K, Rosito TE, Rosito NC, Lobato MIR. Descriptive Study of Gender Dysphoria and Sexual Behavior in a Disorder of Sex Development Group. Front Psychol 2022; 13:652030. [PMID: 36275297 PMCID: PMC9586205 DOI: 10.3389/fpsyg.2022.652030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Disorder of Sex Development (DSD) refers to a heterogeneous group of congenital conditions in which chromosomal, gonadal, and anatomical sex are atypical. Typically, the diagnosis is made at birth or infancy and interventional actions are necessary in many cases. The repercussions in adult life, more specifically in the field of sexuality, have not been not widely studied yet. This study shows research data that seek to identify in a group of individuals with DSD (XX DSD, XY DSD, Chromosomal DSD), who are being monitored in the departments of pediatric surgery and urology of a hospital in the period from 2000 to 2019, and to verify the consequences on sex life after puberty. The sample has 16 participants (7 XY DSD, 4 XX DSD, and 5 Chromosomal DSD), aged between 16 and 50 years, single, with high school education, residents of the state capital and countryside of the state. The results depict the presence of a case of Gender Dysphoria; postponement of sexual debut for almost 3 years compared to the national average; a single sexual relationship for those who have already had a sexual experience with penetration; penis size below the general population average; presence of masturbatory activity in most participants. The presence of sexual attraction and masturbation indicate sexual desire. The group has a late onset of sexual life (almost 3 years after the national average). A recurrent feature in this group is that, even having already performed a penetrative sexual act, there is no continuation in their sexual life. The main noticeable aspect about Gender Dysphoria is the presence of only one case of incongruence in the Chromosomal DSD group. The limited sample prevents us from sufficient statements for generalization.
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Affiliation(s)
- Cesar Augusto Bridi Filho
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- *Correspondence: Cesar Augusto Bridi Filho,
| | - Saulo Batinga Cardoso
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Bianca Machado Borba Soll
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcelo Fröelich Noal
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Karine Schwarz
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Tiago Elias Rosito
- Department of Pediatric Surgery and Department of Urology, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Nicolino Cesar Rosito
- Department of Pediatric Surgery and Department of Urology, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maria Inês Rodrigues Lobato
- Department of Psychiatry and Legal Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Jurek L, Souiller L, Medjkane F. L’identité de genre, entre faits naturels et faits construits, une approche intégrative et développementale. Med Sci (Paris) 2022; 38:808-815. [DOI: 10.1051/medsci/2022128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
À partir des années 1950, l’identité de genre, en ce qu’elle définit la conviction de l’individu d’appartenir à un genre ou à un autre, devient un objet de recherche médicale et scientifique. Partant des premiers travaux de John Money et de Robert Stoller, qui posent la possibilité d’une dimension polyfactorielle de la construction de l’identité de genre, les recherches les plus récentes portant sur les facteurs génétiques, neuroanatomiques, socio-cognitifs et psychodynamiques, réactualisent l’intérêt de pouvoir envisager un modèle polyfactoriel. Le paradigme clinique des variations du développement génital et des troubles du spectre de l’autisme entrouvre des hypothèses quant à l’articulation possible de ces facteurs de différentes natures. Pour appuyer tant ces éléments historiques que les données issues de la recherche actuelle, nous développerons en quoi les pratiques médicales actuelles vis-à-vis du genre s’inscrivent, sur le plan déontologique, dans une approche nécessairement individualisée soutenant un modèle polyfactoriel développemental.
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8
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 639] [Impact Index Per Article: 319.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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9
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O'Connell MA, Atlas G, Ayers K, Sinclair A. Establishing a molecular genetic diagnosis in children with Differences of Sex Development - a clinical approach. Horm Res Paediatr 2021; 96:128-143. [PMID: 34781289 DOI: 10.1159/000520926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite distinct underlying aetiologies, the clinical phenotypes and hormonal profiles of children with various differences of sex development (DSD) are often similar, which presents challenges to ascertaining an accurate diagnosis on clinical grounds alone. Associated features and important clinical outcomes can, however, vary significantly in different DSD, thus establishing an accurate molecular diagnosis may have important implications for decision-making and management planning in a given individual. Summary The wider availability of next generation sequencing techniques in recent years has led to recommendations for earlier integration of genetic testing in the diagnostic pathway of children with DSD. This review provides a practical overview of the clinical applications, advantages and limitations of the more commonly available diagnostic genetic tests and outlines a suggested approach to testing. The potential clinical implications of a confirmed genetic diagnosis on subsequent management pathways for individuals with DSD, as well as challenges that remain to be addressed are also outlined. Key messages Despite significant improvements in our understanding of the complex genetic pathways that underlie DSD, an accurate diagnosis still eludes many affected individuals. Establishing a molecular diagnosis provides aetiological certainty, enabling improved information for families and individualised clinical management, including monitoring or prophylactic intervention where higher longer-term health risks exist. A stepwise approach to genomic testing is recommended to afford highest diagnostic yield from available resources. Looking forward, collaborative multicentre prospective studies will be required to assess the true impact of a genetic diagnosis on improving clinical care pathways and health, wellbeing and patient-reported outcomes for individuals with DSD.
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10
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Kavanaugh GL, Mohnach L, Youngblom J, Kellison JG, Sandberg DE. "Good practices" in pediatric clinical care for disorders/differences of sex development. Endocrine 2021; 73:723-733. [PMID: 34021489 PMCID: PMC8325784 DOI: 10.1007/s12020-021-02748-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/30/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To define, benchmark, and publicize elements of quality care (i.e., "good practices") for pediatric patients with disorders/differences of sex development (DSD). METHODS Principles of quality care were identified by literature review; consensus exists for 11 good practices and adherence was evaluated through online survey of 21 North American clinical sites. RESULTS Strong uptake was observed for many practices, particularly specialty participation (n ≥ 17 of 21 sites for most core specialties); point of contact (n = 18); expertise in gender dysphoria/dissatisfaction (n = 20); and DSD-specific continuing medical education (n = 18). Greater variability was apparent for frequency of peer support referrals (n = 12 universally practiced); standardized questionnaires for routine assessment of psychosocial adaptation (n = 13) and gender development (n = 10); consistently clarifying patient/family values in decision-making (n = 15); genital exam protocols that exclude trainee education as primary reason (n = 15); and internal patient-tracking efforts (n = 5-10 of 20 sites). CONCLUSION This study employed a novel approach to designate DSD good practices and identified areas of consistency and variation in these DSD clinical practices. Good practice benchmarking facilitates quality assessment within and across sites, promotes continuous improvement, and empowers stakeholders in locating and delivering high quality care.
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Affiliation(s)
- Grace L Kavanaugh
- Department of Biology, California State University, Stanislaus, CA, USA
- Accord Alliance, Higley, AZ, USA
| | - Lauren Mohnach
- Fetal Diagnostic and Treatment Center and Differences of Sex Development Clinic, University of Michigan, Ann Arbor, MI, USA
| | - Janey Youngblom
- Department of Biology, California State University, Stanislaus, CA, USA
| | - Joshua G Kellison
- Accord Alliance, Higley, AZ, USA
- Sexual Orientation and Gender Institute of Arizona, Mesa, AZ, USA
| | - David E Sandberg
- Accord Alliance, Higley, AZ, USA.
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA.
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11
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Dwyer AA, Greenspan DL. Endocrine Nurses Society Position Statement on Transgender and Gender Diverse Care. J Endocr Soc 2021; 5:bvab105. [PMID: 34235361 PMCID: PMC8256383 DOI: 10.1210/jendso/bvab105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 11/19/2022] Open
Abstract
The Endocrine Nurses Society (ENS) is committed to clinical excellence in the art and science of endocrine nursing throughout the world. ENS recognizes that transgender and gender diverse (TGD) individuals face challenges and inequities that place them in the realm of health disparities. Further, TGD individuals often face substantial barriers to care and have difficulty finding healthcare providers who are knowledgeable about the unique health needs of this patient population. ENS recognizes that endocrine nurses care for young adult and adult TGD individuals. This position statement outlines recommendations for healthcare providers and organizations seeking to embrace a gender-affirming approach to care and increase access to high-quality, comprehensive care for TGD individuals. This Position Statement was accepted by ENS on September 8, 2020 and has been endorsed by the European Society of Endocrinology Nurse Committee, European Society of Paediatric Endocrinology Nurses, Pediatric Endocrine Nursing Society, Endocrine Nurses' Society of Australasia, and the Federation of International Nurses in Endocrinology.
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Affiliation(s)
- Andrew A Dwyer
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Debra L Greenspan
- Nashville Veteran’s Administration Medical Center, Nashville, TN, USA
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12
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Wall E, Aksglaede L, Haahr ME, Christiansen P, Main KM. Non-Classic Congenital Adrenal Hyperplasia in Two Adolescents With Gender Dysphoria. JOURNAL OF PSYCHOSEXUAL HEALTH 2021. [DOI: 10.1177/26318318211028722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The care of transgender individuals is multidisciplinary including medical, surgical, psychiatric, and psychological health professionals. We here report 2 cases of nonclassic congenital adrenal hyperplasia (CAH) coincidently discovered during the clinical and biochemical evaluation prior to hormonal treatment for gender dysphoria. Elevated 17-OH-progesterone and androstenedione led to further investigations including adrenocorticotropic hormone stimulation test and genetic evaluation of 21CYPA2 confirming the diagnosis of CAH in both individuals. The findings may have implications for future surgical treatment and in the case of transwomen for the choice of antiandrogenic treatment. These cases therefore confirm the importance of thorough clinical and biochemical evaluation of transgender individuals before initiation of hormone therapy.
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Affiliation(s)
- Emma Wall
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lise Aksglaede
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mette Ewers Haahr
- Sexological Clinic, Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Peter Christiansen
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Katharina M. Main
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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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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Carpenter M. Intersex human rights, sexual orientation, gender identity, sex characteristics and the Yogyakarta Principles plus 10. CULTURE, HEALTH & SEXUALITY 2021; 23:516-532. [PMID: 32679003 DOI: 10.1080/13691058.2020.1781262] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/08/2020] [Indexed: 05/28/2023]
Abstract
The 2006 Yogyakarta Principles apply human rights law in relation to sexual orientation and gender identity. Created outside the UN system, their aim was to promote good practices in protecting the rights of LGBT and intersex people. They were ineffective in protecting the rights of intersex people, including due to an inappropriate framing around 'sexual orientation' and 'gender identity'. In the same year, a group of clinicians published a 'consensus statement' reframing intersex traits as 'disorders of sex development', entrenching medical authority over intersex bodies. It was not until 2015 that the first country (Malta) sought to enact protections of rights to bodily integrity and physical autonomy and freedom from discrimination, associated with a new attribute of 'sex characteristics'. In 2017, an update to the Yogyakarta Principles known as the Yogyakarta Principles plus 10 incorporated the new attribute and recognised rights to bodily integrity, truth and legal recognition. These principles have direct relevance to the human rights situation of intersex people. This paper addresses reasons why the earlier Yogyakarta Principles were ineffective and presents the goals of the update process, inviting adoption of a new attribute of sex characteristics and new principles relevant to intersex populations, advocates and policymakers.
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Affiliation(s)
- Morgan Carpenter
- Intersex Human Rights Australia, Sydney, NSW, Australia
- Sydney Health Ethics, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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15
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Babu R, Shah U. Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis. J Pediatr Urol 2021; 17:39-47. [PMID: 33246831 DOI: 10.1016/j.jpurol.2020.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced. METHODS Pubmed/Index medicus were searched for "intersex" [All fields] OR "disorders of sexual differentiation AND "gender identity disorder OR gender dysphoria" [MeSH] for articles published between 2005 and 2020. Typical diagnoses included were congenital adrenal hyperplasia (CAH); complete androgen insensitivity syndrome (CAIS); partial androgen insensitivity syndrome (PAIS); 5 alpha reductase deficiency (5ARD); 17-hydroxysteroid dehydrogenase deficiency (17HSD); mixed gonadal dysgenesis (MGD) and complete gonadal dysgenesis (CGD). GID or gender dysphoria (a strong feeling of dissatisfaction about oneself as male or female) prevalence in DSD patients older than 12 years of age was extracted. Within each condition, GID percentage was compared between female and male rearing. RESULTS The I2statistics for prevalence of GID in DSD showed high heterogeneity with I2 of 93% (95% C.I 90-95%) among the 20 articles included. The overall prevalence of GID among those with DSD was 15% (95% C.I 13-17%). CAH reared females had 4% GID while CAH reared males had significantly higher GID at 15% (p = 0.0056). All CAIS patients were raised as females and the prevalence of GID was 1.7%. GID prevalence was 12% in PAIS raised as females while 25% in those raised as males with no significant difference (p = 0.134). GID was significantly high in 5ARD (53%) and 17HSD (53%) reared as females with half of them virilizing at puberty forcing a gender change. Among sex chromosome DSD 22% of those reared as females had GID while none in those raised as male with no significant difference. CONCLUSIONS GID is low in women with CAH, CAIS and CGD favoring female sex of rearing in these conditions. GID is high in women with 5ARD/17HSD favoring male sex of rearing in these conditions. GID is variable in PAIS or MGD and no recommendations on sex of rearing could be made in these conditions. Each DSD patient is unique and they warrant multi-disciplinary care and long term psycho sexual support.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Utsav Shah
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India
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Ernst MM, Kogan BA, Lee PA. Gender identity: A psychosocial primer for providing care to patients with a disorder/difference of sex development and their families [individualized care for patients with intersex (Disorders/differences of sex development): Part 2]. J Pediatr Urol 2020; 16:606-611. [PMID: 32819812 PMCID: PMC7890938 DOI: 10.1016/j.jpurol.2020.06.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION/BACKGROUND Many parents of infants born with a DSD describe the process of initial sex assignment at birth as highly stressful. Parents of children with a DSD also note high distress when their children engage in behaviors that are not considered typical for their gender. OBJECTIVE The goal of this article is to provide members of the health care team a brief overview of psychosocial facets of gender and gender identity particularly relevant to DSD for the purposes of enhancing shared decision-making and optimizing support for individuals with a DSD and their families. DISCUSSION Gender identity is a multidimensional construct involving related but distinct concepts such as gender typicality, gender contentedness and felt pressure for gender differentiation, and can be assessed via standardized measures. Gender dysphoria is associated with poor psychological adjustment, and is mitigated by family and peer support. Family influences on gender identity include parental modeling of gender behavior and family composition (e.g., same-sex children vs both sons and daughters in a family). Cultural factors that may influence sex assignment include societal views on gender, and gender-related differential resource allocation within a society. In addition, religious beliefs and the presence of a "third-sex" category within a culture may also influence parental gender ideology. CLINICAL APPLICATION Health care providers who work with patients with a DSD must have a strong grasp on the construct of gender identity, and must be able to clearly and consistently communicate with patients and families about gender beliefs in order to optimize family support and gender-related decisions.
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Affiliation(s)
- Michelle M Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA; Differences of Sex Development Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.
| | | | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA.
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Ballering AV, Bonvanie IJ, Olde Hartman TC, Monden R, Rosmalen JGM. Gender and sex independently associate with common somatic symptoms and lifetime prevalence of chronic disease. Soc Sci Med 2020; 253:112968. [PMID: 32272303 DOI: 10.1016/j.socscimed.2020.112968] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 12/15/2022]
Abstract
Sex and gender influence health differently. Associations between sex and health have been extensively studied, but gender (i.e. psychosocial sex) has been largely neglected, partly due to the absence of gender measures in cohort studies. Therefore, our objective was to test the unique associations of gender and sex with common somatic symptoms and chronic diseases, using a gender index created from existing cohort data. We applied LASSO logistic regression to identify, out of 153 unique variables, psychosocial variables that were predictive of sex (i.e. gender-related) in the Dutch LifeLines Cohort Study. These psychosocial variables covered gender roles and institutionalized gender. Using the estimated coefficients, gender indexes were calculated for each adult participant in the study (n = 152,728; 58.5% female; mean age 44.6 (13.1) years). We applied multiple ordinal and logistic regression to test the unique associations of the gender index and sex, and their interactions, with common somatic symptoms assessed by the SCL-90 SOM and self-reported lifetime prevalence of chronic diseases, respectively. We found that in 10.1% of the participants the gender index was not in line with participants' sex: 12.5% of men and 8.4% of women showed a discrepancy between gender index and sex. Feminine gender characteristics are associated with increased common somatic symptoms and chronic diseases, especially in men. Female sex is associated with a higher common somatic symptom burden, but not with a higher prevalence of chronic diseases. The study shows that gender and sex uniquely impact health, and should be considered in epidemiological studies. Our methodology shows that consideration of gender measures in studies is necessary and feasible, based on data generally present in cohort studies.
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Affiliation(s)
- Aranka V Ballering
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands. P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.
| | - Irma J Bonvanie
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands. P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Rei Monden
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands. P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Judith G M Rosmalen
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands. P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
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18
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Faure-Conter C, Orbach D, Fresneau B, Verité C, Bonneau J, Thebaud E, Poirée M, Thouvenin S, Pluchart C, Mure PY, Dijoud F, Morel Y. Disorder of sex development with germ cell tumors: Which is uncovered first? Pediatr Blood Cancer 2020; 67:e28169. [PMID: 32020769 DOI: 10.1002/pbc.28169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/24/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Disorders of sex development (DSD) are rare conditions. Although they are known to predispose to germ cell tumors (GCT), there is a paucity of information regarding the circumstances of DSD discovery. DESIGN/METHODS All patients with DSD registered in two French pediatric GCT protocols (TGM95 and 13) were analyzed. RESULTS Sixteen patients were identified among 276 ovarian, 160 testicular, and 24 mediastinal GCT. Eleven phenotypic females (median age 15 years) exhibited gonadal GCT, including 10 with a 46,XY karyotype and gonadal dysgenesis and one with 46XX,45X0 mosaicism. None had genital anomalies, seven had spontaneous pubertal changes, and one had spontaneous menarche. The tumors were bilateral in four cases. DSD was diagnosed after the GCT diagnosis in seven cases. The reasons for karyotyping were bilateral tumors (3), gonadoblastoma/streak gonad/absence of egg follicles (3), or systematic for GCT (1). The karyotyping was performed before the GCT diagnosis in four cases: for polymalformative syndrome (2) or primary amenorrhea (2). Four males (median age 14 years) exhibited mediastinal GCT (metastatic in two cases) indicative of Klinefelter syndrome, despite typical phenotypes in all cases. The remaining patient had severe hypospadias, leading to the discovery of 46,XY/45,X0 mosaicism before the diagnosis of testicular nonseminomatous GCT at 16 years of age. CONCLUSION DSD are often uncovered at the time of GCT diagnosis (11/16 cases). This should prompt oncologists to rule out a DSD in patients with GCT, even in case of pubertal development. Earlier recognition of Klinefelter syndrome could potentially lead to GCT detection at an earlier stage.
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Affiliation(s)
| | - Daniel Orbach
- Institut Curie, SIREDO Oncology Center, PSL University, Paris, France
| | - Brice Fresneau
- Gustave Roussy Cancer Campus, Pediatric Oncology Unit, Villejuif, France
| | - Cécile Verité
- Department of Pediatric Oncology, Centre hospitalier universitaire, Bordeaux, France
| | - Jacinthe Bonneau
- Department of Pediatric Oncology, Centre hospitalier universitaire, Rennes, France
| | - Estelle Thebaud
- Department of Pediatric Oncology, Centre hospitalier universitaire, Nantes, France
| | - Maryline Poirée
- Department of Pediatric Oncology, Centre hospitalier universitaire, Nice, France
| | - Sandrine Thouvenin
- Department of Pediatric Oncology, Centre hospitalier universitaire, Saint Etienne, France
| | - Claire Pluchart
- Department of Pediatric Oncology, Centre hospitalier universitaire, Reims, France
| | - Pierre Yves Mure
- Department of Pediatric Surgery, Hospices Civils de Lyon, Bron, France
| | - Frederique Dijoud
- Institut de Pathologie Multisite, Groupement hospitalier Est, Hospices Civils de Lyon, UCBL Lyon 1 University, Lyon, France
| | - Yves Morel
- Institut de Pathologie Multisite, Groupement hospitalier Est, Hospices Civils de Lyon, UCBL Lyon 1 University, Lyon, France
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19
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Godfrey LM. Mental health outcomes among individuals with 46,XY disorders of sex development: A systematic review. J Health Psychol 2020; 26:40-59. [PMID: 32133887 DOI: 10.1177/1359105320909863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This review summarizes research on the mental health outcomes of genetic males with a disorder of sex development (46,XY DSD). Databases were systematically searched, yielding 19 studies included in this review. Results varied widely, with mental health outcomes ranging from very poor to similar to comparison groups. A small number of studies demonstrated that patients with hypospadias or complete androgen insensitivity syndrome reported better mental health than patients with other 46,XY (DSD) diagnoses. Future studies should include larger samples of patients within a similar developmental stage, display results separately by DSD diagnosis and gender identity, and consider the potential impact of medical/surgical events on their mental health.
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20
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Grassi S, Morelli V, Arosio M, Buoli M. Gender Identity Fluctuation in a Genetic Female with Late-Onset, Non-Classical Congenital Adrenal Hyperplasia. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1265-1268. [PMID: 30911871 DOI: 10.1007/s10508-019-1440-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/18/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Silvia Grassi
- Department of Psychiatry, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F. Sforza 35, 20122, Milan, Italy
| | - Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Massimiliano Buoli
- Department of Psychiatry, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.
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21
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Faure Conter C, Brindusa Gorduza D, Mure PY, Pracros JP, Mouriquand P, Bouvattier C, Siffroi JP, Plotton I, Gay CL, Cools M, Dijoud F. [Atypical genital development and tumor risk]. Bull Cancer 2019; 106:461-467. [PMID: 30910228 DOI: 10.1016/j.bulcan.2019.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/14/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
Atypical genital development (AGD), also called disorders of sex development are a set of miscellaneous pathologies who have in common a morphological and/or functional abnormality of the internal and/or external genital organs. The Chicago classification identifies 3 major groups based on karyotype, hormone balance and genetic studies. Some AGD predispose to the occurrence of tumors, mainly malignant germ cell tumors. The tumor risk depends on many factors: the type of AGD, the position of the gonad, the age of the patient, the phenotype, the function of the gonad and the presence of germ cells in the gonad. AGD with the highest tumor risk are those with gonadal dysgenesis, implying an incomplete differentiation of the bipotential gonad (dysplasia). Monitoring of patients with AGD and indication of prophylactic gonadectomies should be individualized according to tumor risk.
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Affiliation(s)
- Cécile Faure Conter
- Institut d'hématologie et d'oncologie pédiatrique, IHOPe, 69008 Lyon, France.
| | - Daniela Brindusa Gorduza
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Pierre-Yves Mure
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Jean-Pierre Pracros
- Groupement hospitalier Est, Hospices Civils de Lyon, département de radiologie pédiatrique, 69500 Bron, France
| | - Pierre Mouriquand
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Claire Bouvattier
- Hôpital Bicêtre, département d'endocrinologie pédiatrique, 94270 Le Kremlin Bicetre, France
| | - Jean-Pierre Siffroi
- Hôpital d'Enfants Armand Trousseau, département de génétique médicale, 75012 Paris, France
| | - Ingrid Plotton
- Groupement hospitalier Est, Hospices Civils de Lyon, Centre de biologie moléculaire, 69500 Bron, France
| | - Claire-Lise Gay
- Groupement hospitalier Est, département d'endocrinologie pédiatrique, 69500 Bron, France
| | - Martine Cools
- Hôpital universitaire de Gand, département de médecine interne et de pédiatrie université de Gand, 9000 Gand, Belgique
| | - Frédérique Dijoud
- Groupement hospitalier Est, hospices Civils de Lyon, institut Multisite de pathologie, 69500 Bron, France
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22
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Foreman M, Hare L, York K, Balakrishnan K, Sánchez FJ, Harte F, Erasmus J, Vilain E, Harley VR. Genetic Link Between Gender Dysphoria and Sex Hormone Signaling. J Clin Endocrinol Metab 2019; 104:390-396. [PMID: 30247609 DOI: 10.1210/jc.2018-01105] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT There is a likely genetic component to gender dysphoria, but association study data have been equivocal. OBJECTIVE We explored the specific hypothesis that gender dysphoria in transgender women is associated with variants in sex hormone-signaling genes responsible for undermasculinization and/or feminization. DESIGN Subject-control analysis included 380 transgender women and 344 control male subjects. Associations and interactions were investigated between functional variants in 12 sex hormone-signaling genes and gender dysphoria in transgender women. SETTING Patients were recruited from the Monash Gender Clinic, Monash Health, Melbourne, Australia, and the University of California, Los Angeles. PATIENTS Caucasian (non-Latino) transgender women were recruited who received a diagnosis of transsexualism [Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV) or gender dysphoria (DSM-V)] pre- or postoperatively. Most were receiving hormone treatment at the time of recruitment. MAIN OUTCOME MEASURED Genomic DNA was genotyped for repeat length polymorphisms or single nucleotide polymorphisms. RESULTS A significant association was identified between gender dysphoria and ERα, SRD5A2, and STS alleles, as well as ERα and SULT2A1 genotypes. Several allele combinations were also overrepresented in transgender women, most involving AR (namely, AR-ERβ, AR-PGR, AR-COMT, CYP17-SRD5A2). Overrepresented alleles and genotypes are proposed to undermasculinize/feminize on the basis of their reported effects in other disease contexts. CONCLUSION Gender dysphoria may have an oligogenic component, with several genes involved in sex hormone-signaling contributing.
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Affiliation(s)
| | - Lauren Hare
- Hudson Institute of Research, Melbourne, Victoria, Australia
| | - Kate York
- Hudson Institute of Research, Melbourne, Victoria, Australia
| | | | | | - Fintan Harte
- Monash Gender Clinic, Monash Health, Melbourne, Victoria, Australia
| | | | - Eric Vilain
- Children's National Health System, Washington, DC
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23
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Bessiène L, Lombès M, Bouvattier C. [Differences of Sex Development (DSD): Controversies and Challenges]. ANNALES D'ENDOCRINOLOGIE 2018; 79 Suppl 1:S22-S30. [PMID: 30213302 DOI: 10.1016/s0003-4266(18)31235-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
DSD for "Differences of Sex Development" or "Sexual Differences Development" refers to situations where chromosomal, gonadal or anatomical sex is atypical. DSD 46,XX are mainly represented by congenital adrenal hyperplasia (HCS) and are not a diagnostic issue. DSD 46,XY involve genes for the determination and differenciation of the bipotential gonad, making sometimes difficult the choice of sex at birth. They remain without diagnosis in about half of the cases, despite the new genetic techniques (exome, NGS). The management of DSD is complex as well as are the long-term consequences, particularly in terms of options for medical or surgical treatments, fertility and quality of life of patients that should be discussed. This review describes the main causes of DSD and the recent issues of their clinical management. It addresses the difficult question of identity of these patients, in a society that leaves no place for difference.
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Affiliation(s)
- Laura Bessiène
- Unité INSERM 1185, faculté de médecine Paris-Sud, 63, rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre, France
| | - Marc Lombès
- Unité INSERM 1185, faculté de médecine Paris-Sud, 63, rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre, France; Service d'endocrinologie et de maladies de la reproduction, Assistance publique des hôpitaux de Paris, CHU de Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Claire Bouvattier
- Service d'endocrinologie pédiatrique, Assistance publique des hôpitaux de Paris, CHU de Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre; Centre de référence maladies rares du développement génital, faculté de médecine, Paris-Sud, 63, rue Gabriel-Péri, 94276 Le Kremlin Bicêtre
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24
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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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25
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Nascimento RLP, de Andrade Mesquita IM, Gondim R, Dos Apóstolos RAAC, Toralles MB, de Oliveira LB, Canguçu-Campinho AK, Barroso U. Gender identity in patients with 5-alpha reductase deficiency raised as females. J Pediatr Urol 2018; 14:419.e1-419.e6. [PMID: 30297225 DOI: 10.1016/j.jpurol.2018.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 08/27/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVE 5-Alpha reductase type 2 deficiency (5-ARD) is a rare disorder of sex development. The lack of 5-alpha reductase, an enzyme that converts testosterone into dihydrotestosterone, results in external genitalia that may appear female, or predominantly male, albeit undervirilized, or, more often, ambiguous. METHODS This study describes a series of patients with 5-ARD raised as female, focusing on aspects related to gender identity. Following a retrospective chart review, patients with 5-ARD were invited to return to the clinic to enable their gender identity to be assessed using an 11-item structured in-house questionnaire. The Golombok-Rust Inventory of Sexual Satisfaction was applied to patients who had initiated their sexual life. RESULTS Six patients aged >15 years with 5-ARD and raised as female were included. Most patients were diagnosed late: two before and four after puberty. The mean length of the phallus was 2.8 cm (0.5-5.0). Reasons for seeing a doctor included genital appearance (n = 3), amenorrhea/absence of breast development (n = 2), and changes in gender role attitudes (n = 1). According to the gender identity assessment, 4 patients identified as female, 1 as male, and 1 as both genders. Only the patient identified as male requested gender re-assignment. Of the two patients who had initiated their sexual life, sexual satisfaction was found to be good in one and poor in the other due to vaginal discomfort during intercourse. CONCLUSION In the present series, the majority of undervirilized patients with a diagnosis of 5-ARD raised as female were in complete conformation with being female and described themselves as heterosexual. The more virilized patients were those least in conformity with their female-assigned gender.
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Affiliation(s)
- R L P Nascimento
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - I M de Andrade Mesquita
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - R Gondim
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - R A A C Dos Apóstolos
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - M B Toralles
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - L B de Oliveira
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - A K Canguçu-Campinho
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil
| | - U Barroso
- Disorders of Sexual Development Multidisciplinary Clinic, Federal University of Bahia, Salvador, Bahia, Brazil.
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26
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Gomes NL, Lerário AM, Machado AZ, Moraes DRD, Silva TED, Arnhold IJP, Batista RL, Faria Júnior JAD, Costa EF, Nishi MY, Inacio M, Domenice S, Mendonca BB. Long-term outcomes and molecular analysis of a large cohort of patients with 46,XY disorder of sex development due to partial gonadal dysgenesis. Clin Endocrinol (Oxf) 2018; 89:164-177. [PMID: 29668062 DOI: 10.1111/cen.13717] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 04/06/2018] [Accepted: 04/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Follow-up data on patients with 46,XY partial gonadal dysgenesis (PGD) until adulthood are scarce, making information on prognosis difficult. OBJECTIVE To analyse the long-term outcomes of patients with 46,XY PGD regarding testosterone production, germ cell tumour risk, genotype and psychosexual adaptation. METHODS A retrospective longitudinal study of 33 patients (20 assigned male and 13 patients assigned female at birth). Molecular diagnosis was performed by Sanger sequencing or by targeted massively parallel sequencing of 63 genes related to disorders of sex development (DSDs). RESULTS Age at first and last visit ranged from 0.1 to 43 and from 17 to 53 years, respectively. Spontaneous puberty was observed in 57% of the patients. During follow-up, six of them had a gonadectomy (four due to female gender, and two because of a gonadal tumour). At last evaluation, five of six patients had adult male testosterone levels (median 16.7 nmol/L, range 15.3-21.7 nmol/L) and elevated LH and FSH levels. Germ cell tumours were found in two postpubertal patients (one with an abdominal gonad and one patient with Frasier syndrome). Molecular diagnosis was possible in 11 patients (33%). NR5A1 variants were the most prevalent molecular defects (n = 6), and four of five patients harbouring them developed spontaneous puberty. Gender change was observed in four patients, two from each sex assignment group; all patients reported satisfaction with their gender at final evaluation. Sexual intercourse was reported by 81% of both gender and 82% of them reported satisfaction with their sexual lives. CONCLUSION Spontaneous puberty was observed in 57% of the patients with 46,XY PGD, being NR5A1 defects the most prevalent ones among all the patients and in those with spontaneous puberty. Gender change due to gender dysphoria was reported by 12% of the patients. All the patients reported satisfaction with their final gender, and most of them with their sexual life.
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Affiliation(s)
- Nathalia L Gomes
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Antônio Marcondes Lerário
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Aline Zamboni Machado
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniela Rodrigues de Moraes
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Thatiana Evilen da Silva
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ivo J P Arnhold
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rafael Loch Batista
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Antônio Diniz Faria Júnior
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elaine F Costa
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mirian Y Nishi
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marlene Inacio
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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27
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Rothacker KM, Ayers KL, Tang D, Joshi K, van den Bergen JA, Robevska G, Samnakay N, Nagarajan L, Francis K, Sinclair AH, Choong CS. A novel, homozygous mutation in desert hedgehog ( DHH) in a 46, XY patient with dysgenetic testes presenting with primary amenorrhoea: a case report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2018; 2018:2. [PMID: 29507583 PMCID: PMC5834851 DOI: 10.1186/s13633-018-0056-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/22/2018] [Indexed: 11/10/2022]
Abstract
Background Desert hedgehog (DHH) mutations have been described in only a limited number of individuals with 46, XY disorders of sex development (DSD) presenting as either partial or complete gonadal dysgenesis. Gonadal tumours and peripheral neuropathy have been associated with DHH mutations. Herein we report a novel, homozygous mutation of DHH identified through a targeted, massively parallel sequencing (MPS) DSD panel, in a patient presenting with partial gonadal dysgenesis. This novel mutation is two amino acids away from a previously described mutation in a patient who presented with complete gonadal dysgenesis. Adding to the complexity of work-up, our patient also expressed gender identity concern. Case presentation A 14-year-old, phenotypic female presented with primary amenorrhoea and absent secondary sex characteristics. Investigations revealed elevated gonadotrophins with low oestradiol, testosterone of 0.6 nmol/L and a 46, XY karyotype. Müllerian structures were not seen on pelvic ultrasound or laparoscopically and gonadal biopsies demonstrated dysgenetic testes without neoplasia (partial gonadal dysgenesis). The patient expressed gender identity confusion upon initial notification of investigation findings. Formal psychiatric evaluation excluded gender dysphoria. Genetic analysis was performed using a targeted, MPS DSD panel of 64 diagnostic and 927 research candidate genes. This identified a novel, homozygous mutation in exon 2 of DHH (DHH:NM_021044:exon2:c.G491C:p.R164P). With this finding our patient was screened for the possibility of peripheral neuropathy which was not evident clinically nor on investigation. She was commenced on oestrogen for pubertal induction. Conclusion The evaluation of patients with DSD is associated with considerable psychological distress. Targeted MPS enables an affordable and efficient method for diagnosis of 46, XY DSD cases. Identifying a genetic diagnosis may inform clinical management and in this case directed screening for peripheral neuropathy. In addition to the structural location of the mutation other interacting factors may influence phenotypic expression in homozygous DHH mutations.
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Affiliation(s)
- Karen M Rothacker
- 1Department of Endocrinology and Diabetes, Princess Margaret Hospital, Subiaco, WA Australia.,11Department of Endocrinology and Diabetes, Princess Margaret Hospital, GPO Box D 184, Perth, WA Australia
| | - Katie L Ayers
- 2Murdoch Childrens Research Institute, Melbourne, VIC Australia.,3Department of Paediatrics, The University of Melbourne, Melbourne, VIC Australia
| | - Dave Tang
- 4Telethon Kids Institute, Subiaco, WA Australia
| | - Kiranjit Joshi
- 1Department of Endocrinology and Diabetes, Princess Margaret Hospital, Subiaco, WA Australia
| | | | | | - Naeem Samnakay
- 5Department of Paediatric Surgery, Princess Margaret Hospital, Subiaco, WA Australia.,6School of Surgery, The University of Western Australia, Crawley, WA Australia
| | - Lakshmi Nagarajan
- 7Department of Neurology, Princess Margaret Hospital, Subiaco, WA Australia.,8School of Paediatrics and Child Health, The University of Western Australia, Crawley, WA Australia
| | - Kate Francis
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA Australia
| | - Andrew H Sinclair
- 2Murdoch Childrens Research Institute, Melbourne, VIC Australia.,3Department of Paediatrics, The University of Melbourne, Melbourne, VIC Australia.,Victorian Clinical Genetics Service, Melbourne, VIC Australia
| | - Catherine S Choong
- 1Department of Endocrinology and Diabetes, Princess Margaret Hospital, Subiaco, WA Australia.,8School of Paediatrics and Child Health, The University of Western Australia, Crawley, WA Australia
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28
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Desafíos urológicos en la transición de pacientes pediátricos hacia la adultez. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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29
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Campo-Engelstein L, Chen D, Baratz AB, Johnson EK, Finlayson C. The Ethics of Fertility Preservation for Pediatric Patients With Differences (Disorders) of Sex Development. J Endocr Soc 2017; 1:638-645. [PMID: 28944319 PMCID: PMC5607629 DOI: 10.1210/js.2017-00110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Differences (disorders) of sex development are diverse conditions with variations in chromosomal, gonadal, and/or genital development. Fertility potential in this population is variable. Recent investigations into fertility potential in those previously thought to be infertile suggest that the majority may have fertility potential through experimental protocols. Fertility preservation may be more successful if pursued in childhood. As fertility research and techniques advance, it is important to carefully consider pediatric ethical issues specific to this population, including gonadectomy, consent/assent, experimental treatment and false hope, cost and insurance coverage, genetic transmission to offspring, and gender dysphoria.
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Affiliation(s)
- Lisa Campo-Engelstein
- Alden March Bioethics Institute, Department of Obstetrics and Gynecology, Albany Medical College, Albany, New York 12208
| | - Diane Chen
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Arlene B Baratz
- Division of Breast Imaging, West Penn Allegheny Health System, Temple University School of Medicine, Pittsburgh, Pennsylvania 15212
| | - Emilie K Johnson
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Courtney Finlayson
- Division of Pediatric Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
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30
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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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31
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32
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Congenital Aphallia: Review of Pathogenesis and Current Treatment Guidelines. Urology 2015; 86:384-7. [DOI: 10.1016/j.urology.2015.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 04/16/2015] [Accepted: 04/27/2015] [Indexed: 11/21/2022]
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33
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Ekenze SO, Nwangwu EI, Amah CC, Agugua-Obianyo NE, Onuh AC, Ajuzieogu OV. Disorders of sex development in a developing country: perspectives and outcome of surgical management of 39 cases. Pediatr Surg Int 2015; 31:93-9. [PMID: 25326123 DOI: 10.1007/s00383-014-3628-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Improvements in diagnostic testing and genital repair have significantly advanced the management of disorders of sex development (DSD). Challenges however, still exist in the management of DSD. This study evaluated the types, challenges of surgical management, and outcome of DSD in south-east Nigeria. METHODS Retrospective analysis of 39 children with DSD managed from January 2005 to December 2013 at the University of Nigeria Teaching Hospital, Enugu, Nigeria. RESULTS Types of DSD were: 46, XX DSD in 17 (43.6 %) cases; 46, XY DSD 16 (41 %); Ovotesticular DSD 5 (12.8 %); and one (2.6 %) 46, XY Ovotesticular DSD. Median age at definitive gender assignment was 3 years (range 2 months-14 years). Gender assignment was female for 20 (51.3 %; all 46, XX DSD, one each of 46, XY DSD, Ovotesticular DSD and 46, XY Ovotesticular DSD), and male for 19 (48.7 %; 15 of 46, XY DSD, 4 of Ovotesticular DSD). Eight cases reared as male before presentation required gender reassignment after evaluation and counselling. Genital repair was undertaken at mean age of 4.1 years (range 6 months-14 years). After average follow-up of 22.5 months (range 1 month-7 years), a total of eleven (28.2 %) developed procedure-related complications. Challenges were delayed diagnosis, inadequate diagnostic facilities, and need for gender reassignment. CONCLUSION There is a wide spectrum of DSD in our setting. Time to diagnosis, evaluation, and outcome may be improved by public enlightenment initiative, focused education of healthcare personnel and provision of relevant diagnostic facilities through enhanced funding and collaboration.
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Affiliation(s)
- S O Ekenze
- Sub-Department of Paediatric surgery, University of Nigeria Teaching Hospital Enugu, Enugu, 400001, Nigeria,
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34
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Rothkopf AC, John RM. Understanding disorders of sexual development. J Pediatr Nurs 2014; 29:e23-34. [PMID: 24796516 DOI: 10.1016/j.pedn.2014.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 04/03/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022]
Abstract
Studies estimate that the incidence of genital anomalies could be as high as 1 in 300 births. While it is rare for an infant to present with truly ambiguous genitalia, it is plausible that the pediatric nurse will encounter a patient with disorders of sexual development in his or her career. Cases of disorders of sexual development are challenging due to complexities of diagnosis, gender assignment, uncertain outcomes, treatment options, and psychosocial stressors. This article discusses the evaluation and management of children with disorders of sexual development and the nurse's role as child advocate and family educator.
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35
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van der Zwan YG, Callens N, van Kuppenveld J, Kwak K, Drop SLS, Kortmann B, Dessens AB, Wolffenbuttel KP. Long-term outcomes in males with disorders of sex development. J Urol 2013; 190:1038-42. [PMID: 23507395 DOI: 10.1016/j.juro.2013.03.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Indications that the prenatal action of testosterone in the brain is an important determinant of gender development and improved reconstructive techniques have caused a shift in male gender assignments in patients with 46XY disorders of sex development. We report long-term outcome data on psychosexual development and sexual function of these individuals in a cross-sectional study. MATERIALS AND METHODS Physical status of 14 men with a mean age of 25 years with disorders of sex development was assessed by structured interview and physical examination. Psychosexual outcome was evaluated by questionnaires and compared to a control group of 46 healthy, age matched men. RESULTS A total of 13 men underwent 1 to 6 (mean 2) genital surgeries. Mean age at first surgery was 2.7 years. Mean penile length was 6.6 cm. All men reported erections and were able to experience orgasms. Ejaculatory dysfunction was reported by 7 men. Mean penile length was 7.9 cm in patients who were able to achieve penetrative intercourse and 4.9 cm in those who were not. Meatus was glanular in 5 patients, coronal in 7 and at the distal shaft in 1. Compared to controls, men with disorders of sex development were less satisfied with the appearance of the penis and scrotum but not with total body image. These patients reported decreased sexual desire and activities. CONCLUSIONS Outcome in this group of men with disorders of sex development was poor regarding penile length, ejaculation, satisfaction with external genitalia and frequency of sexual activity. Other aspects, such as overall body image and psychosexual functioning, showed no difference from controls.
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Affiliation(s)
- Yvonne G van der Zwan
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus MC-Sophia, Rotterdam, The Netherlands.
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