Intersex

A model to study human ovotesticular syndrome

Ovotesticular syndrome is a rare disorder of sex development characterized by the presence of testicular and ovarian tissue. The histologic characteristics of human testicular tissue are well defined by the presence of seminiferous cords or tubules containing TSPY-positive germ cells and Sox9-positive Sertoli cells surrounded by interstitial tissue containing cytochrome P450-positive Leydig cells and smooth muscle α-actin-positive peritubular myoid cells. The histological characteristics of the ovary can be defined by germ cell nests and the development of follicles. In contrast to the testis, the ovary has a paucity of defined specific protein markers, with the granulosa cell marker FOXL2 being the most widely used. In practice, defining the ovarian component of the ovotestis can be quite difficult. We developed a model of human ovotesticular syndrome by combining fetal human testis and ovary in a xenograft model. Ovotesticular xenografts were grown under the renal capsules of gonadectomized athymic nude mice for 6-32 weeks along with age matched control grafts of fetal testis and ovary. Forty ovotesticular xenografts and their controls were analyzed by histology, immunohistochemistry, and fluorescent in situ hybridization to determine the protein expression and karyotype of the cells within the grafts. The ovotesticular xenografts exhibited recognizable testicular and ovarian tissue based on testis-specific and ovary-specific markers defined above. The xenografts simulated a bipolar ovotestis in which the testicular and ovarian elements retain their separate histological characteristics and are separated by a well-defined border. This contrasts with the compartmentalized ovotestis previously described in the literature where the testicular tissue is surrounded by ovarian tissue or a mixed histology where testicular and ovarian tissues are interspersed throughout the gonad. In conclusion, we have characterized a human model of ovotestis which will allow a deeper understanding of ovotestis development in humans and facilitate a more accurate diagnosis of the ovotesticular syndrome.

Sports Medicine Research Practices for Categorizing Transgender and/or Intersex Participants

CONTEXT

Approximately 1 to 1.4 million individuals (0.58% of the population) in the United States identify as transgender, yet no literature could be found regarding how researchers should adapt clinical research studies when intersex or transgender individuals volunteer as participants. Therefore, the objective was to determine if there is a consensus among recently published researchers in 3 athletic training and sports medicine journals regarding procedures used to categorize participants and data of transgender or intersex individuals in a research study.

METHODS

The authors developed a 14-item survey using Qualtrics XM to assess how researchers categorize individuals and their data when intersex or transgender individuals volunteer to participate in clinical research studies that are not intended to focus on intersex or transgender individuals. The survey was sent to 378 individuals in athletic training and related fields who recently published research manuscripts from 2018 to 2020 in one or more of 3 leading journals in the field including the Journal of Athletic Training, the Journal of Sport Rehabilitation, and the Athletic Training and Sports Health Care Journal.

RESULTS

A total of 82 respondents completed the survey, yielding a response rate of 21.69%. When categorizing research participants who were not using hormones or surgery to transition, several respondents were unsure how to categorize transgender individuals (n = 14, 17.1%) or intersex individuals (n = 35, 42.7%). If the research participant was using hormones and/or surgery to transition, many respondents were unsure how to categorize the sex of the individual (n = 27, 32.9%). Only 5 (6.1%) respondents indicated that their organization has policies that guide their inclusion of transgender and/or intersex individuals in research studies.

CONCLUSIONS

There does not appear to be consensus among researchers who recently published in athletic training and sports medicine journals regarding how to categorize transgender and intersex individuals who volunteer to participate in research studies.

Ambiguous genitalia in the newborn: an overview and teaching tool

Ambiguous genitalia is a significant example of a disorder of sexual development, in which the external genitalia do not have the typical appearance of either sex. Although the birth of a child with ambiguous genitalia is rare, the emergent nature of the issue demands that healthcare providers have at least a familiarity with the underlying etiologies, the issues, and the initial approach to diagnosis and management. With numerous etiologies, potential difficulties with reaching a diagnosis, and many challenges with immediate and long-term care, the topic of ambiguous genitalia can be daunting. We provide a review of basic embryology, as well as a classification system for understanding the various etiological causes of ambiguous genitalia. The important clinical aspects of diagnosis and management are also highlighted, and a teaching tool has been included to help the reader (or their learners) to solidify information presented. Our overall goal is to provide practical information on ambiguous genitalia and allow the clinician to apply this information to clinically relevant scenarios.

[Obvious aspects of the external genitalia in disorders of sexual differentiation]

Birth of a child with intersexual external genitalia poses a severe psychological burden for the parents. Therefore, it is of utmost importance to find the correct diagnosis quickly. Inspection of the genitalia might already give important hints. Serological and molecular genetic examinations can verify the diagnosis in the majority of cases. Chromosomal analysis is obligatory.To understand the different appearances of intersexual genitalia, first the normal embryological sexual differentiation is explained in the article. Then the aspects of virilized genitalia in cases of a chromosomal 46,XX child and of female appearing genitalia in cases of a chromosomal 46,XY child are described. Differences are analysed. Besides mentioning the main causes of disorders in sexual differentiation a brief summary of diagnostics and therapeutic considerations is given.

Laparoscopic surgery in 46,XX disorder of sex development: hysterosalpingectomy with gonadectomy

PURPOSE

We present the outcomes of one of the largest series specifically of laparoscopic hysterosalpingectomy with bilateral gonadectomy in 46,XX patients with congenital adrenal hyperplasia raised as a male.

PATIENTS AND METHODS

From June 2005 to March 2008, five patients raised as male were treated at our institution using laparoscopic surgery. 46,XX disorder of sex development was diagnosed in all the patients because of congenital adrenal hyperplasia. Hysterosalpingectomy with bilateral gonadectomy was performed completely laparoscopically in all five patients.

RESULTS

All procedures were completed with minimal blood loss. The duration of the surgeries was 70-125 minutes. There were no complications during surgery or conversion to open surgery. The hospital stay ranged from 1 to 2 days, except in one patient who presented urinary retention and was discharged from the hospital a week after the surgery.

CONCLUSIONS

Laparoscopic surgery can be safely used as part of the diagnosis and treatment of 46,XX disorder of sex development. Laparoscopy can be useful in the diagnosis as well as surgical management of Müllerian structures as well as intraabdominal gonads contrary to social sex.

Environment, testicular dysgenesis and carcinoma in situ testis

The testicular dysgenesis syndrome (TDS) hypothesis proposes that a proportion of the male reproductive disorders-cryptorchidism, hypospadias, infertility and testicular cancer-may be symptoms of one underlying developmental disease, TDS, which is most likely a result of disturbed gonadal development in the embryo. TDS may be caused by genetic factors, environmental/life-style factors, or a combination of both. Some rare disorders of sex development of genetic origin are among the best-known examples of severe TDS. Among the environmental and life-style factors that are suspected to influence the hormonal milieu of the developing gonad are the endocrine disrupters. A prenatal exposure to commonly used chemicals, e.g. phthalates, may result in a TDS-like phenotype in rats. Currently, this animal model is the best model for TDS. In humans the situation is much more complex, and TDS exists in a wide range of phenotypes: from the mildest and most common form, in which impaired spermatogenesis is the only symptom, to the most severe cases, in which the patient may develop testicular cancer. It is of great importance that clinicians in different specialties treating patients with TDS are aware of the association between the different symptoms.

As novas definições e classificações dos estados intersexuais: o que o Consenso de Chicago contribui para o estado da arte?

As anomalias da diferenciação sexual têm-se constituído em um formidável desafio quanto ao diagnóstico e à conduta, colocando o paciente, os familiares e os profissionais da equipe de saúde na difícil situação de definir a melhor opção quanto ao gênero de criação. Uma terminologia confusa e estigmatizante tem sido adotada e, nesse sentido, o Consenso de Chicago propõe várias modificações no sentido de minimizar os desconfortos graças a uma terminologia que nem sempre auxilia na solução de problemas. Os autores fazem uma análise crítica da classificação sugerida pelo Consenso, levantando a questão de que, na nova classificação, também não se resolvem certos problemas terminológicos e continua a se criar algum grau de estigmatização. Em primeiro lugar, a sugestão de se incluir o cariótipo no nome da doença supõe, erroneamente, que os pacientes não tenham conhecimento do que significa ser 46,XY ou 46,XX. Uma criança criada no sexo feminino com uma anomalia da diferenciação sexual (ADS) 46,XY não vai entender porque está no sexo feminino se seu cariótipo é "masculino". A substituição do termo hermafroditismo verdadeiro por ADS ovotesticular está longe de resolver o problema de estigmatização causado por "hermafroditismo". O termo ovotesticular é claramente entendido como uma fusão entre ovário e testículo e não será aceito com "naturalidade". Se, por um lado, é muito satisfatório que a questão da nomenclatura seja discutida, por outro lado devemos escolher termos alternativos que sejam realmente neutros e não tragam, em si, a conotação de um sexo que pode não condizer com o escolhido para aquele paciente em particular. Um ponto em que todos concordamos é que a substituição de intersexo por anomalia da diferenciação sexual (ADS) ou, disorder of sex development (DSD), na língua inglesa, cai muito melhor e não dá a conotação de um "sexo intermediário" como o nome antigo proporcionava.

Intersex: four cases in one family

Intersex presents a unique challenge to modern medicine. Generally, patients with ambiguous genitalia present in the neonatal period. Due to functional failure of the assigned gender role, some patients may be discovered later in life, as in the presented cases. The four patients, all members of the same family and aged 23, 15, 13 and 4 years, presented with ambiguous genitalia. The family history revealed parental consanguinity and one additional case of genital ambiguity. The eldest two patients had developed gynaecomastia during puberty. Examination of the genitalia revealed penoscrotal hypospadias and bifid scrotum in all the four. Gonads were palpable bilaterally in three of the patients, but in the fourth only one gonad was palpable. Buccal smear was negative for sex chromatin in all the cases. On abdominal ultrasound Müllerian structures were found in the two eldest patients. The karyotype in all four cases was determined as 46XY. Gonadal biopsies revealed immature testicular tissue and azoospermia, as sometimes seen in cryptorchidism. We conclude that these cases should be classified as dysgenetic male pseudohermaphrodites, a rare variety of ambiguous genitalia. In agreement with the patients and their parents, they were assigned the male gender and surgery was performed accordingly. We stress the need for active involvement of patient and parents in the process of gender assignment and awareness of hasty decision making.

Male pseudohermaphroditism in a Labrador Retriever, and a review of mammalian sexual differentiation

CASE HISTORY

An 8-month-old Labrador Retriever was referred with a history of ambiguous external genitalia.

CLINICAL FINDINGS AND TREATMENT

Clitoromegaly within apparent vulval folds, and an adjacent subcutaneous mass were noticed on external examination. An intra-abdominal testicle, with epididymis and suspected vas deferens ducts, was found during exploratory celiotomy. Incision over the subcutaneous mass revealed the accompanying testicle. Clitoridectomy was performed and an os clitoris removed. Normal juvenile testes were diagnosed on histology of the gonads. Chromosomal studies revealed a normal 78, XY male chromosomal constitution. Due to the combination of a male karyotype (78, XY), the presence of testicular tissue in the gonads, and the appearance of the external genitalia, a diagnosis of male pseudohermaphroditism (MPH) was made.

CLINICAL RELEVANCE

This case presents the first report of MPH in a Labrador Retriever, and highlights the diagnostic steps recommended when confronted with a dog with ambiguous external genitalia.

Intersex embodiment: when health care means maintaining binary sexes

The treatments carried out with intersex children for the purpose of helping them live in a normatively gendered world have raised increasing levels of controversy in the past decade. This paper outlines key debates that are taking place highlighting the relevance of critical approaches to evidence. It points to the value of working across disciplines and epistemological frameworks in order to fundamentally re-think existing clinical practice in terms of ethical concerns and in terms of the reported experiences of intersex people.

SRD5A2 gene analysis in an Italian population of under-masculinized 46,XY subjects

OBJECTIVE

The differential diagnosis of male under-masculinization, including a wide spectrum of phenotypes and a heterogeneous genetic basis, is crucial for the correct management of the patients. To characterize an Italian population of under-masculinized males, we performed the molecular analysis of the SRD5A2 gene (2p23), encoding the 5alpha-reductase-2 enzyme that converts testosterone (T) to dihydrotestosterone (DHT), and is required for full masculinization of the male foetus.

DESIGN AND PATIENTS

Twenty-six Italian patients with 46,XY kariotype and various degrees of ambiguous genitalia were retrospectively selected for this study. Twelve of these patients, 10 of whom were referred for partial androgen insensitivity syndrome (PAIS), were raised as females; 15 were raised as males and all had a severe hypospadias. For most of the patients, the case histories and hormonal findings were incomplete but all could be included in the clinical characteristics of under-masculinization.

MEASUREMENT

For hormonal evaluation, T and DHT were measured by means of radioimmunoassay (RIA) and high-performance liquid chromatography (HPLC)-RIA methods, respectively. Genomic DNA of all patients and relatives was extracted from peripheral blood, the five exons of the SRD5A2 gene were amplified by polymerase chain reaction (PCR) and submitted to automatic sequencing.

RESULTS

Five known mutations affecting the NADPH binding function and one new mutation affecting the enzyme C-terminus were identified in a total of eight patients (two of whom were sisters). Five families were characterized, and in two patients only one affected allele was observed. The extension of the analysis to the regions flanking exons allowed the identification of a new polymorphism in intron 2, whose frequency was determined.

CONCLUSION

This first report of an Italian population underlines the importance of differential diagnoses in patients with under-masculinization. The lack of precise genotype-phenotype correlation in some of the mutations highlights the necessity to improve knowledge about the biochemical aspects of steroid 5alpha-reductase action and about the interactions of genetic and environmental factors.

Transsexual Genital Self-Mutilation

Most genital self-mutilations in nonpsychotic patients are found in transsexuals, and premeditation of sex-conversion surgery is the main objective. In this paper, we will describe the case of a male-to-female transsexual who took out his testes as a way to facilitate the surgery and to circumvent the Brazilian laws.

Correlation between genotype, phenotype and sex of rearing in 111 patients with partial androgen insensitivity syndrome

OBJECTIVE

Partial androgen insensitivity syndrome (PAIS) is a heterogeneous group of intersex disorders characterized by a typical perineoscrotal hypospadias/micropenis phenotype, and a normal androgen-producing testis. Various mutations in the androgen receptor (AR) are known to cause PAIS. Phenotypic expression is widely variable and there are no agreed guidelines to determine the sex of rearing in individuals with borderline masculinization. We aimed to quantitatively assess the external genital phenotype in relation to AR genotype and sex of rearing and identify criteria that differentiate mutation positive (ARmt) from mutation negative (ARwt) PAIS patients.

PATIENTS AND DESIGN

Cases with a diagnosis of PAIS were identified from the Cambridge Intersex Database. An external masculinization score (EMS) was used to quantify the degree of undermasculinization. Family history of AIS and details of the sex of rearing were recorded. Androgen binding was analysed in fibroblasts obtained from genital skin biopsies and mutational analysis of the AR was performed on genomic DNA extracted from peripheral blood. EMS and sex of rearing were compared in cases with similar mutations reported on the McGill International Database.

RESULTS

Two hundred and sixty-three patients with PAIS were identified. Androgen receptor gene sequencing was performed in 111 patients. Twenty-seven (24%) had mutations. Family history of AIS was present in 61 and 21% of ARmt and ARwt patients, respectively. The median EMS was 3 in both groups. The majority of ARmt patients had abnormal binding and there was a tendency to a higher median testosterone rise on hCG stimulation in ARmt (9.3 nmol/l) compared with ARwt patients (6.9 nmol/l). All patients with EMS of 4 or more were raised as male but there was an overlap of sex of rearing in patients with an EMS less than 4. A wide variation of EMS in relation to genotype and sex of rearing was observed.

CONCLUSION

The phenotype in PAIS is extremely variable and is rarely predicted by the AR genotype. Apart from the family history, there are no specific criteria to differentiate ARwt from ARmt. Sex of rearing is not entirely dependent on the EMS. Cultural issues, other modifying genes and response to androgen trials might be influencing factors. Collaborative studies with uniform protocols are needed to investigate infants with PAIS. Documenting phenotype, surgical procedures and outcome criteria are necessary to enable decision-making on the sex of rearing in patients with a lower range EMS.

Practical management of the intersex infant

Intersex occurs when the appearance of the internal or external genitalia is at variance with normal development for either sex. The first question asked by, and of new parents in relation to their offspring is often "Is it a boy or a girl"? A rational approach, based on knowledge of normal prenatal sexual development, and based on a careful physical examination to guide further investigation, is required to reach a diagnosis. We briefly review prenatal sexual development to provide a background to the assessment of genital ambiguity in the newborn. Aspects of physical examination are discussed in detail, with reference to published normative data where possible. We provide a classification of genital ambiguity and an approach to differential diagnosis. We highlight some of the many syndromes associated with genital ambiguity, with reference to their genetic basis where possible. In 46,XX individuals, the commonest cause of genital ambiguity is congenital adrenal hyperplasia due to 21-hydroxylase deficiency; however, in 46,XY individuals the differential diagnosis is wide, and may remain unexplained, even after extensive investigation. Two algorithms are presented, one of which provides an initial approach based on the presence of a uterus and palpable gonads alone, and a second illustrating a comprehensive differential diagnosis of the undervirilised 46,XY individual. We discuss our approach to sharing information on the diagnosis and management with the parents and highlight the early involvement of an experienced multidisciplinary team. Finally, we consider current controversial issues relating to gender assignment and management of genital ambiguity.

A female pseudohermaphrodite Holstein heifer with gonadal mosaicism

An 11-month-old Holstein heifer diagnosed as a female pseudohermaphrodite (PH) was subjected to clinical, hormonal, histological, and cytogenetic examinations. The urogenital sinus and external genitalia of the heifer were virilized and no vulval orifice was present. A male urethra-like tubular structure was palpable in the perineal area; urination occurred through a urethral fossa at the distal end of the urethra (cranial aspect of the mammary tissue). Bilateral ovaries and uterine horns, ovarian follicular development, ovulation and CL formation (with increasing blood P4 concentration) were similar to a normal heifer. Testosterone (T) concentrations of all samples collected both before and after hCG challenge were <0.1 ng/mL (absence of a responsive endogenous androgen source). Histologically, the ovary, uterus, oviduct and vagina resembled the normal female reproductive tract. Although the corpus cavernosum was present, the penile urethra and corpus spongiosum penis were hypoplastic. A normal female karyotype (60, XX) was detected in metaphase spreads obtained from cultured peripheral lymphocytes. Moreover, Y-chromosome-specific sequences were not detected in genomic DNA from lymphocytes. By PCR analysis of genomic DNA (from the tissues of urogenital organs), Y-chromosome-specific sequences (both SRY and Amelogenin (Amel) locus) were detected. In conclusion, this was a female PH heifer due to gonadal mosaicism, with normal female genitalia and ovarian activity. This is the first report of an SRY-positive, mosaic female PH heifer.

Psychosexual development in genetic males assigned female: the cloacal exstrophy experience

Genetic males who have cloacal exstrophy, a rare, severe pelvic field defect that leads to aphallia, traditionally have been socially, legally, and surgically sex-assigned female at birth and reared female, despite a male karyotype and a typical male prenatal hormonal milieu. Psychosexual development in such children previously has been unknown. Studies of 29 children revealed that despite the absence of the typical postnatal and pubertal androgen surges and the presence of female genitalia, all female-assigned subjects displayed a marked male-typical shift in psychosocial and psychosexual development. Nearly half of them have declared themselves male. Psychosexual development, including gender identity, in genetic and hormonal male neonates seems to be influenced heavily by prenatal androgen exposure. The clinical practice of surgical sex assignment at birth requires re-evaluation.