Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice

"I've had constant fears that I'll get cancer": the construction and experience of medical intervention on intersex bodies to reduce cancer risk

PURPOSE

This paper examines the subjective experience of medical interventions on intersex bodies to reduce cancer risk.

METHODS

Twenty-five individuals with intersex variations took part in semi-structured interviews, analysed through thematic discourse analysis.

RESULTS

Intersex bodies were positioned as inherently sick and in need of modification, with cancer risk legitimating surgical and hormonal intervention. This resulted in embodied shame, with negative impacts on fertility and sexual wellbeing. However, many participants resisted discourses of bio-pathologisation and embraced intersex status. Some medical interventions, such as HRT, were perceived to have increased the risk of cancer. Absence of informed consent, and lack of information about intersex status and the consequences of medical intervention, was positioned as a human rights violation. This was compounded by ongoing medical mismanagement, including health care professional lack of understanding of intersex variations, and the objectification or stigmatization of intersex people within healthcare. The consequence was non-disclosure of intersex status in health contexts and lack of trust in health care professionals.

CONCLUSIONS

The legitimacy of poorly-evidenced cancer risk discourses to justify medical intervention on intersex bodies needs to be challenged. Healthcare practitioners need to be provided with education and training about cultural safety practices for working with intersex people.

Working towards convergence of the clinical management of differences of sex development/intersex conditions and the human rights framework: A case study

OBJECTIVE

Medical treatments that aim to modify the appearance of the genitals in children who are born with a difference of sex development/intersex (DSD/I*) condition are highly controversial. Human Rights bodies worldwide have argued that such treatments are conflicting with the child's right of personal autonomy and should be legally restricted to the unique situation where the child's physical health is in danger.

DESIGN

We here review the current status of legal initiatives in Europe that have addressed the issue of medical treatments in minors who have a DSD for which they have not been able to give personal informed consent due to their young age.

PATIENTS

The management of a 3 years old child who has congenital adrenal hyperplasia (CAH) and grows up with atypical-looking genitals is discussed.

RESULTS

In spite of extensive psychosocial support to the child and family from birth onwards, and good medical control of CAH, the child develops signs of emotional distress, suspected to be attributable to the genital difference. Our discussions include perspectives from the multidisciplinary DSD team caring for the child, a human rights specialist, and an intersex activist. From our discussions, we conclude that with evolving medical care, new ethical and human rights challenges are raised. A truly holistic human rights approach should not only consider physical but also mental health and psychosocial and psychosexual adaptation of the child to the medical condition, when reflecting on the acceptability of medical treatments in minors for which no personal informed consent can be obtained due to their young age. In addition it is paramount to include the meaningful participation of the child in the clinical management at the earliest possible stage.

CONCLUSIONS

Continued convergence of clinical management and the human rights framework can be realised based on constructive discussions involving all stakeholders, and with the best interest of the child - and adult that they will become - as a common goal.

Navigating the disclosure landscape: Parents' perspectives on healthcare professionals' role in supporting intersex children and families

Intersex, an umbrella term, describes individuals with sex characteristics that cannot be exclusively categorized into binary definitions of male or female. The intersex community faces a lack of social visibility perpetuated by a history of medical discrimination and pathologization shaped by "normalizing" genital surgeries without the child's consent. Despite efforts to reform clinical practice, there remains a paucity of research centering the needs of the intersex community and their families. This study explored parents' perspectives on how healthcare professionals (HCPs), such as genetics professionals, can provide patient-centered education and support when parents first learn of their child's intersex variation, with the aim of offering recommendations to HCPs to promote parental adjustment and protect intersex children's right to autonomy. Thirteen qualitative semi-structured interviews were conducted with 14 parents of intersex children. Through reflexive thematic analysis, under the framework of an agency-based approach to intersex health, thematic categories were inductively conceptualized, including barriers and facilitators to HCPs' sensitivity and to parental adjustment in the early disclosure environment. Barriers to HCPs' sensitivity were imposed by educational, religious, or medical institutions, along with sociocultural prejudices and pathologizing language. Barriers to parental adaptation included uncertainty regarding their child's future, sociocultural gender norms, and unsuitable information provision. Incorporating parental needs in the disclosure environment can facilitate familial acceptance, including normalization of variations of sex characteristics (VSCs), enhanced medical education, facilitation of patients' navigation, and prioritization of parents' social support needs.

Towards equity & inclusion: a critical examination of genetic Counselling Education on Intersex Healthcare

BACKGROUND

Intersex describes a diversity of individuals with variations in sex characteristics (VSC), reflecting underlying differences in reproductive anatomy, hormones, and/or genes and chromosomes. With a shift towards socially-conscious clinical practices, genetic counsellors (GCs) are increasingly needing to provide comprehensive care to individuals with VSC and their families. However, the current quality of training provided to genetic counsellors on intersex health is unclear.

METHODS

Qualitative interviews were conducted between Jan-Feb 2021 with 20 current and graduated students of Canadian GC training programs to assess the quality of GC education on intersex health topics. An agency-based model of VSC health as proposed by Crocetti et al. was used to guide the inductive thematic data analysis.

RESULTS

Results revealed three key themes: limited discussions on psychosocial considerations when caring for intersex individuals, enthusiasm for integrating more intersex training into the curriculum, and personal initiative in ensuring equity and justice in the care of individuals with VSC.

CONCLUSIONS

These findings demonstrate existing knowledge gaps in the GC curriculum, with a need to increase the profession's overall awareness on intersex issues. GC training programs have an opportunity to meet the desires of students while promoting person-centered and validating healthcare for the intersex community.

A relational approach to youth healthcare: Examining young people's, parents' and clinicians' experiences in the context of variations in sex characteristics

According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts.

Differences of sex development and surgical decisions: focus group interviews with health care professionals in Norway

Background

Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals' (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process.

Methods

Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis.

Results

Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child's and caregivers' needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals.

Conclusion

HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents' wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.

The Appropriateness of Medical Devices Is Strongly Influenced by Sex and Gender

Until now, research has been performed mainly in men, with a low recruitment of women; consequentially, biological, physiological, and physio-pathological mechanisms are less understood in women. Obviously, without data obtained on women, it is impossible to apply the results of research appropriately to women. This issue also applies to medical devices (MDs), and numerous problems linked to scarce pre-market research and clinical trials on MDs were evidenced after their introduction to the market. Globally, some MDs are less efficient in women than in men and sometimes MDs are less safe for women than men, although recently there has been a small but significant decrease in the sex and gender gap. As an example, cardiac resynchronization defibrillators seem to produce more beneficial effects in women than in men. It is also important to remember that MDs can impact the health of healthcare providers and this could occur in a sex- and gender-dependent manner. Recently, MDs' complexity is rising, and to ensure their appropriate use they must have a sex-gender-sensitive approach. Unfortunately, the majority of physicians, healthcare providers, and developers of MDs still believe that the human population is only constituted by men. Therefore, to overcome the gender gap, a real collaboration between the inventors of MDs, health researchers, and health providers should be established to test MDs in female and male tissues, animals, and women.

A Life Course Perspective on the Sexual Development of Young Intersex People

Previous research has indicated that intersex people face specific challenges in their sexual development, including uncertainties or confusion about their gender, a negative genital self-image, and hesitance to engage in romantic and sexual relationships. However, in-depth knowledge regarding a central period in this development, adolescence, is missing. In our qualitative study, we explore which factors influence the relational and sexual development of intersex youth and what elements contribute to positive development. We interviewed eighteen intersex persons aged 18-38. We identified three main themes: (1) intersex experiences, (2) the described sexual and relational life course, and (3) factors influencing a positive development. Our findings show that intersex youth face many obstacles in their relational and sexual development, many of which are related to healthcare. However, their life stories also illuminate how healthcare professionals, as well as parents, friends, partners, teachers, and others, can make a substantial difference in intersex lives by breaking normative, binary thinking on sex and gender.

Understanding sexual health concerns among adolescents and young adults with differences of sex development: a qualitative study

PURPOSE

Differences of sex development (DSD) are congenital conditions that involve variations in individuals' sex chromosomes, genes, external and/or internal genitalia, hormones, and/or secondary sex characteristics. This study sought to elucidate the experiences of adolescents and young adults living with DSD by focusing on their experiences of intimacy and sexual health.

METHODS

An interpretative phenomenological research design was adopted. Semi-structured qualitative interviews were conducted with 11 Norwegian adolescents and young adults aged 16-26 years who had five different DSD conditions. The interview findings were analysed by means of a reflexive thematic analysis.

RESULTS

The participants reported feeling different, both in terms of how their body functioned and how their body looked. Lack of knowledge increased this feeling of differentness. Moreover, lack of everyday language with which to talk about intimacy and sexual concerns resulted in the participants feeling stigma. Anticipating stigmatization and lacking everyday language complicated the participants' communication regarding their DSD and sexual health.

CONCLUSIONS

The sexual experiences of adolescents and young adults with DSD are diverse. Fear of stigmatization and lack of everyday language complicate communication with healthcare professionals and others. Understanding their unique needs is crucial to helping individuals achieve good sexual health.

Medical Mistrust Mediates the Relationship Between Nonconsensual Intersex Surgery and Healthcare Avoidance Among Intersex Adults

BACKGROUND

Intersex individuals experience poor health due, in part, to healthcare avoidance. Nonconsensual intersex surgery may contribute to medical mistrust and avoidance among intersex populations.

PURPOSE

The purpose of this study was to explore the relationship between nonconsensual surgery and healthcare avoidance among intersex populations and to examine if medical mistrust mediates this relationship.

METHODS

Data for this cross-sectional study were collected in 2018 and analyzed in 2022. Participants completed a survey collecting information on demographics, medical mistrust, history of nonconsensual surgery, and history of postponing healthcare. One hundred nine participants with valid responses to all regression model variables were included in the study. Multivariable logistic regression models controlling for age, race, and income, examined the relationship between nonconsensual surgery and postponing preventive and emergency healthcare. Mediation analyses of cross-sectional data examined whether medical mistrust mediated the relationship between nonconsensual surgery and postponing preventive and emergency healthcare.

RESULTS

Mean medical mistrust score was 2.8 (range = 1-4; standard deviation = 0.8), 49.7% of participants had nonconsensual surgery in their lifetime, 45.9% postponed emergency healthcare, and 61.5% postponed preventive healthcare in their lifetime. Nonconsensual surgery was associated with increased odds of delaying preventive (adjusted odds ratio [AOR] = 4.17; confidence interval [CI] = 1.76-9.88; p = .016) and emergency healthcare (AOR = 4.26; CI = 1.71-10.59; p = .002). Medical mistrust mediated the relationship between nonconsensual surgery and delaying preventive (indirect effect = 1.78; CI = 1.16-3.67) and emergency healthcare (indirect effect = 1.66; CI = 1.04-3.30).

CONCLUSIONS

Nonconsensual surgery contributed to healthcare avoidance in this intersex population by increasing medical mistrust. To decrease healthcare avoidance, intersex health promotion interventions should restrict nonconsensual surgery and build trust through trauma-informed care.

Intersex people's perspectives on affirming healthcare practices: A qualitative study

Intersex people have variations in their sex characteristics that do not exclusively fall within binary definitions of male and female. This community experiences discrimination in the medical setting due to the pathologization of intersex bodies, including 'normalizing' genital surgeries without the child's consent. While research has explored biomedical aspects contributing to intersex variations, there is limited research centering intersex people's perspectives on their healthcare experiences. The aim of this qualitative study was to understand the experiences of intersex people in the medical setting, with the goal of providing recommendations to clinicians to promote affirming healthcare practices. Between November 2021 and March 2022 we conducted 15 virtual semi-structured interviews with members of the intersex community about their experiences with healthcare providers and perspectives on how their care could be improved. Participants were recruited through social media, with the majority residing in the United States. Through reflexive thematic analysis, 4 major themes were conceptualized: (1) the exclusion of intersex people in binary frameworks, (2) the common experience of medical trauma, (3) the value of psychosocial support, and (4) systemic change to address intersex healthcare. Recommendations were generated based on participants' narratives, including a recommendation for providers to use a trauma-informed approach to care. Healthcare providers must prioritize patient autonomy and ensure consent throughout their medical visits in order to promote intersex affirming care. Depathologization of intersex variations and comprehensive teachings of intersex history and medical care must be incorporated into medical curricula to mitigate experiences of medical trauma and to relieve the burden placed on patients to be their own medical experts and advocates. Participants shared the value of being connected to support groups and mental health resources. Systemic change is needed for the normalization and demedicalization of intersex variations and for the medical empowerment of the intersex community.

Public understanding of intersex: an update on recent findings

Surgical interventions on infants with intersex characteristics are considered justified by some on the grounds that they carry a high risk of intolerable stigma. However, public understanding of intersex and its medicalization are under-researched. We review recent qualitative and quantitative studies of the understandings of intersex and its medicalization among people who have no particular professional or public experience of intersex. First, such laypeople reason about clinical dilemmas by drawing on values in similar ways as expert healthcare professionals do. Second, laypeople can over-estimate the utility of current 'umbrella terms,' including intersex, for people with direct familial experience of intersex. Third, beliefs about good and bad effects of medical intervention are affected by framing intersex as either a medical condition or the natural basis for a social identity. Fourth, sexual identity is the best evidenced predictor of opinions about early surgical intervention and its legal limitation on human rights grounds. We argue that possible stigmatizing reactions from the public may not be a solid basis on which to justify early surgical intervention on intersex characteristics.

The psychology of people with variable sex characteristics/intersex

Psychological research on people with variable sex characteristics (VSC)/intersex is broadening from the traditional exploitation of this population to ask nature/nurture questions about sexuality and gender. Healthcare for this population has been highly controversial, prompting research on psychological outcomes, the life-span development of adults with VSC, and distress trajectories of parents of children with VSC. Psychological research on clinical psychologists' roles in multidisciplinary care teams, and on decision making about medical pathways informed by those teams, both inform the evaluation of contemporary healthcare. Research is broadening to consider schoolchildren with VSC, elite athletes with VSC, and public understanding of VSC. The growing interdisciplinary field of intersex studies provides critical resources for psychologists.

Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH)

Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.

Hypospadias surgery: understanding parental emotions, decisions and regrets

This paper builds an argument about genital surgery in the context of medical treatment of children and young people with variations in sex characteristics. First, I set out what is known from existing research including psychological research, surgical follow-up studies and parental regret studies. Second, I present an analysis of surgeons' talk about children, young people and parents in relation to genital surgery. This paper focuses most specifically on hypospadias surgery, but the argumentation is relevant for other kinds of genital surgery carried out in the context of genital variations. The questions guiding this paper are: what research evidence supports hypospadias surgery and what research evidence brings this surgery into question? How might a new interpretation of the evidence, in light of psychosocial research and human rights concerns, contribute to a new perspective on elective genital surgery on minors with variations in sex characteristics? I draw out implications for clinicians supporting parents to decide whether a surgical pathway is the best option for their child.

A 15–20-year follow-up of mental health, psychosocial functioning and quality of life in a single center sample of individuals with differences in sex development

Background: The aim of the study was to present metal health, psychosocial functioning and quality of life (QoL) of children and adolescents with a difference in sex development (DSD) from their first visit in the newly established multidisciplinary team in 2002–2004 in Norway. A secondary aim was to explore mental health, psychosocial functioning and QoL in the same cohort patient’s as for today and finally explore any childhood predictors for these outcomes in adulthood.

Methods: The first part of the study took place in 2002–2004 in a mixed cohort of children and adolescents born with a DSD in 1982–2002, compared to a healthy comparison group. This part involved semi-structured interviews and self-reported and proxy-reported questionnaires. The second part of the study is a longitudinal study of the same participants 15–20 years later (2018–2020).

Results: The participants at baseline of the study consisted of 33 patients; 24 assigned females (congenital adrenal hyperplasia, androgen insensitivity syndrome, gonadal dysgenesis and ovotesticular DSD) and nine assigned males; all with a hypospadias diagnosis. Significant differences were found for behavioral and emotional problems between groups, 46, XX females with significant higher total scores on YSR (49.43 + 24.17, p  = .047); 46, XY females (21.00 + 12.04, p  = .032); and higher internalizing problems scores (YSR) in 46, XX females (16.57 + 9.74), compared with the 46, XY females (5.60 + 5.32, p = .047). A positive association between QoL of the participants in adulthood and PedsQL’ social function (r = .657, p = .020) and psychosocial function in childhood (r = .596, p = .041) was found.

Conclusions: In summary, this study demonstrated that adolescents assigned females with DSD might have more psychiatric problems and a poorer degree of psychosocial functioning compared to a healthy comparison group. As we do find an association with these problems in adolescence and later adult QoL, it is of great importance to respond to these behaviors in early life.

Enduring uncertainties. Medical accounts on caring for young people with variations of sex characteristics

Objectives

The diagnosis of intersex or variations of sex characteristics (VSC) often has a big impact on families who fear social stigmatization. Research has shown that intersex populations often experience important health disparities and that poor mental health and daily function are common among youth with VSC. The present study aimed to explore what healthcare professionals of adolescents and young adults (AYA) with VSC find important in terms of care to this group of patients.

Methods

Semi-structured interviews were conducted with Swiss healthcare providers involved in the care of youth born with an intersex variation. The qualitative data were analyzed using reflexive thematic analysis.

Results

Analysis resulted in six major themes: (1) With regard to patients' and families lived experiences, interviewees reported that fertility was as a major issue for parents but not for intersex youth as they were said to live in the moment. (2) Respondents considered various forms of psycho-social care (professional support, peer support and informal support from family and friends) to be of fundamental importance for their patients, but many of them seemed critical about support from advocacy groups and activists. All healthcare providers reported significant gaps in (3) the transition process and (4) the establishment of multidisciplinary care teams due to structural, provider- and patient-related barriers. (5) Participants were in favor of a more holistic and patient-centred care approach and (6) were critical about the medicalized use of DSD (disorder of sex development) with patients and families.

Conclusion

These findings suggest that although clinicians work hard to implement a holistic approach to care, their intentions are often undercut by a desire to hold a position of medical control. Healthcare professionals need to come to see medical uncertainty not only as a threat but also as an opportunity.

Die Erfassung von Geschlecht

Zusammenfassung. Die Abfrage von Geschlecht hat sich als Standard für die Erfassung von soziodemografischen Daten etabliert. In den meisten Fällen wird dabei nur global nach der Zuordnung zum weiblichen oder männlichen Geschlecht gefragt. Tatsächlich ist Geschlecht aber ein multidimensionales Konstrukt, das auf unterschiedlichste Aspekte verweisen kann: juristische, biologische, psychologische, soziale etc. Auf keiner dieser Ebenen reichen die binären Optionen zur Beschreibung aus. In diesem Beitrag informieren wir daher – von Mehrdimensionalität ausgehend – über empirisch fundierte sowie forschungsethisch gebotene Formen der Erhebung von Geschlecht. Der Fokus liegt dabei auf den Wünschen und Bedarfen von in der Forschung marginalisierten Gruppen: 179 Personen, die sich als trans*, nicht-binär oder inter* (unterrepräsentiert: N = 2) verorten bzw. angaben, momentan ihr Geschlecht zu hinterfragen, sowie 121 dyadische cis Personen bewerteten 5 verschiedene Formate der Geschlechtserhebung. Trotz unterschiedlicher Bewertungen bei allen Formaten zeigte sich eine klare Präferenz für ein freies Eingabefeld zur Angabe des Geschlechts, das optional auszufüllen war. Vor- und Nachteile der einzelnen Erhebungsformen werden kritisch reflektiert und allgemeine Empfehlungen für die Forschungspraxis ausgesprochen.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

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.

Health intervention experiences and associated mental health outcomes in a sample of LGBTQ people with intersex variations in Australia

People with intersex variation/s have sex characteristics determined by reproductive anatomy or chromosomal, gonadal, or hormonal expressions that are not typical of medical and societal norms for male or female bodies and are widely subjected to irreversible medical interventions at an early age to reinforce sex assignment. These interventions may be accompanied by experiences of lack of autonomy for the individual and, at times, lack of fully informed consent on the part of the individual or their parents/carers. People with intersex variations additionally experience high rates of mental health concerns relating to stigma, discrimination and poor healthcare experiences. The intersections between LGBTQ identities and intersex variations are poorly understood but are important given a high proportion of people with intersex variations identify as LGBTQ. This study explored associations between healthcare experiences and mental health outcomes among 46 LGBTQ people aged between 18 and 67 years old with intersex variations in Australia. Findings provide evidence of associations between suicidal thinking, suicidal attempts, depression or anxiety and negative healthcare experiences, including limited autonomy and consent, and challenges accessing psychological support. These highlight the need for further research and proactive intervention to advance human rights and improve health outcomes for this population.

The neglect of sex: A call to action for including sex as a biological variable in placebo and nocebo research

Sex differences exist in the prevalence, progression and treatment efficacy of a wide array of medical conditions. While the placebo and nocebo effects have become increasingly relevant in the clinical arena, little is known about the influence of biological sex on placebo and nocebo effects. This paper discusses the existing, relatively limited and sometimes conflicting evidence about how sex impacts the occurrence and magnitude of the placebo and nocebo effects, mainly focusing on pain studies. We present recent evidence that when compared to men, women suffering from chronic orofacial pain may derive greater benefit from the placebo effect for analgesia. Nonetheless, we broadly argue that the field is not currently positioned to draw definitive conclusions and propose several important factors that may explain the inconsistency in the literature and that should be taken into account in future research. These include the specific target symptom of the placebo or nocebo manipulation and whether or not the target is related to the medical condition, the placebo or nocebo induction method, the sex of the experimenter or physician, and so forth. Future research should intentionally include sex a biological variable to favor translation of placebo and nocebo mechanisms into clinical applications.

Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.

Protective Factors for LGBTI+ Youth Wellbeing: A Scoping Review Underpinned by Recognition Theory

Considerable research has been undertaken regarding the mental health inequalities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of societal and individual prejudice, stigma and discrimination. Far less research has focussed on protective factors that promote wellbeing for this population. A scoping review was conducted using a six-stage methodological framework, and is reported in accordance with the PRISMA-ScR statement. This explored the extent, range and nature of the peer-reviewed, published, academic literature on what is known about the protective factors that promote LGBTI+ youth wellbeing. Six databases were systematically searched applying Population–Concept–Context key inclusion criteria, complemented by contact with authors to identify additional sources, reference checks and hand searches. Ninety-six individual research records were identified and analysed, drawing from Honneth’s Recognition Theory. Interpersonal relations with parents (n = 40), peers (n = 32) and providers (n = 22) were associated with indicators of enhanced wellbeing, as were LGBTI+ community relations (n = 32). Importantly, online (n = 10), faith (n = 10) and cultural (n = 5) communities were potentially protective. Content and thematic analysis highlighted the importance of Gay–Straight Alliances (GSAs) (n = 23) offering powerful protective opportunities through intersecting interpersonal, community and legal forms of recognition. GSAs enhance allyship by peers and providers (n = 21), facilitate access to LGBTI+ community networks (n = 11) and co-exist alongside inclusive policies (n = 12), curricular (n = 5) and extracurricular activities (n = 1). This scoping review underscores the need to move beyond the predominant focus on risk factors for LGBTI+ youth, which subsequently inform protectionist approaches. It concludes with an appeal to develop mechanisms to apply recognitive justice to policy, practice and, importantly, future research directions. This emphasises the salience of enhanced understandings of inclusion, which is rights-based, universally available and of potential benefit to all.

Intersex adolescents seeking help for their depression: the case study of SPARX in New Zealand

OBJECTIVE

SPARX is a computerized cognitive behavioral therapy self-help program for adolescent depression that is freely available in New Zealand. At registration, users identify themselves as either male, female, intersex, or transgender. We aimed to describe the mental health of adolescent intersex users.

METHOD

A secondary analysis of SPARX usage data over 5 years.

RESULTS

Of the 8922 adolescents users, 0.6% (n = 50) identified as intersex. Based on Patient Health Questionnaire 9 - modified for Adolescents (PHQ-A) results, 78.3% of intersex users had high levels of depression and/or self-harm and suicidal ideation. The mean PHQ-A scores for intersex users were significantly higher than for males and females (p < .001). As only three intersex users completed SPARX Level 4 or more (of the seven-level program), we were unable to meaningfully investigate any reductions in their depressive symptoms over time.

CONCLUSIONS

There is a dearth of empirical data on the mental health of intersex adolescents. These results suggest that intersex adolescents seeking help from an online resource have high mental health needs compared with other young people, possibly because they defer seeking help.

Disorders or Differences of Sex Development? Views of Affected Individuals on DSD Terminology

Over a decade ago, the participants at the International Consensus Conference on Intersex proposed Disorders of Sex Development (DSD) as an umbrella term for "congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical". The Group recommended the terminology be sensitive to concerns of individuals having these conditions. Yet, controversy rages over the term DSD. This multicentre clinical evaluation study was initiated as part of the European research group dsd-LIFE to evaluate patient-reported outcome. In total, 1,040 individuals with conditions labeled as Disorders of Sex Development were recruited in Poland, Sweden, Germany, France, United Kingdom and the Netherlands. All participants were asked to rate the terms describing their conditions. Overall, a large majority of participants (69%) reported that the term Disorders of Sex Development applied to their condition or that they felt neutral about it. Most participants preferred terms that were specific to their somatic condition. Overall, our data do not support the view that, in general, the term Disorders of Sex Development is insensitive to concerns of affected persons and that it should therefore be abandoned. However, in the clinical encounter, we recommend that clinicians evaluate each patient's preferences.

Young people with a variation in sex characteristics in Aotearoa/New Zealand: identity, activism and healthcare decision-making

Young people born with variations in sex characteristics (VSC) or disorders of sex development (DSD) face numerous challenges in navigating issues relating to identity and to their lived and embodied experience. There is limited published research amplifying the voices of young people with a VSC, especially from Aotearoa/New Zealand. This qualitative study provides an up-to-date picture of the lived experience of 10 young people with a VSC in Aotearoa/New Zealand. The research was conducted in collaboration with the advocacy group, Intersex Youth Aotearoa, and explored the level of support provided by health services, peers and advocacy groups in relation to the ways the participants viewed themselves and their bodies, and their health related decision-making. Findings reveal the pressure on young people with a VSC to conform to cultural and societal norms, specifically, heteronormative and traditional constructs of how male and female bodies should look in Aotearoa/NZ society. Such views, often held and perpetuated by health professionals and parents, contributed to complexities surrounding identity, agency and acceptance of difference experienced by these young people. The implications of these findings are discussed, including the need for better psychological and peer support for young people.

Young Voices: Sexual Health and Transition Care Needs in Adolescents with Intersex/Differences of Sex Development-A Pilot Study

STUDY OBJECTIVE

To determine the sexual health and well-being needs of current generations of youth with intersex/Differences of Sex Development (DSD) during transition from pediatric to adult health care.

DESIGN

Qualitative narrative analyses, quantitative descriptives, and questionnaires.

SETTING

Peer support networks and outpatient clinics.

PARTICIPANTS

Eighteen adolescents aged 16-21 years with intersex/DSD.

INTERVENTIONS

Semi-structured interviews and/or survey.

MAIN OUTCOME MEASURES

Youths learning about bodily differences, their sexual experiences and motives (eg, agency, pleasure), body image, sexual communication inside and outside of health care, and perceived gaps between current and ideal transitional care. Quantitative and qualitative content of the surveys and interviews were analyzed to identify key topics.

RESULTS

We found that (1) there is a need for open-minded perceptions of health care providers about what it means to have a sex variation: (2) there is a need for continued support and information about lived realities relating to the diagnosis and treatments as well as experiential aspects of sexuality: and (3) there are communication obstacles with providers in a multidisciplinary team setting as well as with parents.

CONCLUSION

A user-centered care perspective for adolescents with sex variations includes their stories and feedback toward service improvement. This pilot study shows that adolescents want to be more involved in their sexual health care in ways that connect to their specific questions. Their desire for information increases as they grow older, and underlines the most essential lesson that health care providers can bring their patients about their bodies: how to care for, respect, and enjoy them.

An experimental philosophical bioethical study of how human rights are applied to clitorectomy on infants identified as female and as intersex

Clitorectomies performed on the genitals of infants identified as female and as intersex have been described both as similar procedures and as different procedures. The former types of surgery have been recognised more consistently as human rights abuses than the latter in recent decades. We tested social psychological explanations of why human rights are differently recognised when infants are described as 'intersex' or 'female'; 122 laypeople in the UK read one of two near-identical descriptions of clitorectomies performed on intersex or female infants and reported their agreement with 22 items about the human rights of such infants. Clitorectomies were perceived as violating human rights more by women than by men, and more so when infants were described as female than intersex. Endorsement of human rights was better predicted by several psychological variables when infants were described as female than as intersex. Less politically conservative participants, as assessed by a Right-Wing Authoritarianism measure, and participants who trusted medical authority more recognised human rights violations of female infants more than intersex infants. Results are discussed with respect to human rights efforts to protect infants from medically non-necessary genital surgery on the basis of membership in identity categories or possession of sex characteristics.

'That decision really was mine…'. Insider perspectives on health care controversies about intersex/diverse sex development

After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of 'optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of 'full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family. Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically. Findings indicate that while 'full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.

Towards an agency-based model of intersex, variations of sex characteristics (VSC) and DSD/dsd health

Agency-based approaches to the health of intersex people and those with DSD focus on bodily autonomy and the cessation of normalising medical interventions until an under-age person can exercise fully informed choice regarding treatment. Discussions regarding intersex agency and health care can be inspired by the social model of health that emerged from disability theory. However, a purely social model is insufficient to address the harms that has been caused by DSD medical interventions, and the healthcare needs that some intersex people have. Drawing on original empirical research conducted in Italy, Switzerland and the UK, this article explores agency-based approaches to intersex and DSD, incorporating the social model's critique of the pathologisation of bodily diversities, whilst supporting the provision of effective healthcare where needed. The article addresses healthcare deficits and their cultural underpinnings. It identifies key impediments to intersex agency, including body normativity and sex and gender binarism. While there has been slight movement towards an agency-based approach to intersex in some national medical settings in the last ten years, there is still a need for change to the conceptualisation of intersex/DSD and subsequent revisions to healthcare provision.

Psychosocial care and support in the field of intersex/diverse sex development (dsd): counselling experiences, localisation and needed improvements

From different sides, there is a call for better psychosocial care and counselling in the field of diverse sex development (dsd). However, studies on the specific demands, deficits and needed improvements regarding those services are rare. This exploratory online study aimed at investigating counselling experiences and the ideas that different groups of participants have concerning the localisation of counselling structures and improving care. Quantitative and qualitative data (N = 630) were analysed within a mixed methods framework. The participants included experts of experience resp. patients with different intersex/dsd conditions (n = 40), parents of children with dsd (n = 27), professional psychosocial counsellors (n = 321) and experts in the field including medical practitioners, psychologists, natural and social scientists as well as others involved, e.g., students or relatives (n = 56). The results show a gap between receiving psychosocial and medical care in the group of adult lived-experience experts, who had received less psychosocial care than medical interventions. The findings also reveal important tasks of psychosocial care. A focus was set on parental experiences. Helpful aspects reported were talking with other parents of children with intersex/dsd, aspects missed were assistance in supporting the individual development of their children. The majority of all participants (58%) held the view that, apart from multidisciplinary competence centres, there also have to be easily accessible counselling services which offer support in everyday life. The participants named increasing quality and quantity as necessary improvements in counselling structures for children and adults with intersex/dsd and their families. Implications are drawn for the specific tasks and target groups of psychosocial care and needed research in intersex healthcare over life span.

'Does anyone else have this?' The role of emotion in forum discussions about medical conditions affecting sex characteristics

When people experience rare medical conditions or variations, searching online may be the only way to find others with similar experiences. This study examines what happens when people do just that. The dataset for the research has been generated from online posts by people living with variations of sex characteristics, which some call intersex variations. Our analysis focuses on how emotion appears in online posts, how affect becomes embodied in digital contexts, and how norms are negotiated as people relate to one another about the variations that some of them experience. We offer an analysis grounded in digital affect theory to contribute to health research literature. We suggest how health researchers and healthcare providers might develop more nuanced understandings of the emotional realities of people living with variations of sex characteristics.

Drawing the Line Between Essential and Nonessential Interventions on Intersex Characteristics With European Health Care Professionals

Human rights statements on intersex characteristics distinguish legitimate “medically necessary” interventions from illegitimate normalizing ones. Ironically, this binary classification seems partially grounded in knowledge of anatomy and medical interventions; the very expertise that human rights statements challenge. Here, 23 European health professionals from specialist “disorder of sex development” (DSD) multidisciplinary teams located medical interventions on a continuum ranging from “medically essential” to nonessential poles. They explained their answers. Participants mostly described interventions on penile/scrotal, clitoral/labial, vaginal, and gonadal anatomy whose essential character was only partially grounded in anatomical variation and diagnoses. To explain what was medically necessary, health care professionals drew on lay understandings of child development, parental distress, collective opposition to medicalization, patients “coping” abilities, and patients’ own choices. Concepts of “medical necessity” were grounded in a hybrid ontology of patients with intersex traits as both physical bodies and as phenomenological subjects. Challenges to medical expertise on human rights grounds are well warranted but presume a bounded and well-grounded category of “medically necessary” intervention that is discursively flexible. Psychologists’ long-standing neglect of people with intersex characteristics, and the marginalization of clinical psychologists in DSD teams, may contribute to the construction of some controversial interventions as medically necessary.

A Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance

Extensive research documents the health inequalities LGBTI people experience, however far less is known for people with intersex variation. This paper presents a review of intersex health and healthcare inequalities by evaluating research published from 2012 to 2019. In total 9181 citations were identified with 74 records screened of which 16 were included. A synthesis of results spans nine quantitative, five qualitative and two narrative reviews. Literature was searched in Medline, Web of Science, Cochrane, PsycInfo and CINAHL. People with intersex variance experience a higher incidence of anxiety, depression and psychological distress compared to the general population linked to stigma and discrimination. Progressive healthcare treatment, including support to question normative binaries of sex and gender, aids understand of somatic intersex variance and non-binary gender identity, especially when invasive treatment options are avoided or delayed until individuals are able to self-identify or provide consent to treatment. Findings support rethinking sex and gender to reflect greater diversity within a more nuanced sex-gender spectrum, although gaps in research remain around the general health profile and the healthcare experiences of people with intersex variance. More large-scale research is needed, co-produced with peers who have lived experience of intersex variation to ensure policy, education and healthcare advances with greater inclusivity and ethical accountability.

Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent

INTRODUCTION

Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion.

AIM

The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions.

METHODS

A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis.

MAIN OUTCOME MEASURE

Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making.

RESULTS

The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence.

CONCLUSION

The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.

What is known about the protective factors that promote LGBTI+ youth wellbeing? A scoping review protocol

Background: There is much concern at the substantial vulnerabilities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of discrimination, stigmatisation and marginalisation. Recent research highlights the importance of understanding factors that can promote wellbeing for this population. This paper presents a protocol for a scoping review which aims to systematically map and synthesise the extent and nature of the peer-reviewed, published and unpublished academic literature on the protective factors that promote wellbeing for sexual and gender minority young people. Methods: In accordance with the methodological framework for scoping reviews, the following six stages will be undertaken: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation will be used throughout the review process. Key inclusion criteria will use the Population, Concept, Context approach, with two reviewers independently conducting the screening and extraction stages across five databases. Identified protective factors will be collated, summarised and categorised iteratively by one reviewer in consultation with the review team. Stakeholder consultation is a key strength of the scoping review process and will be complemented by the public patient involvement of LGBTI+ young people with expertise by experience. Conclusions: The scoping review has the potential to inform policy, practice and future research through enhanced understandings of the complex interplay of factors that promote wellbeing for sexual minority, gender minority and intersex youth. This first stage of the research process will inform the development of a larger research project. The findings will be disseminated through a peer reviewed publication, a conference presentation and by sharing the findings with key stakeholders, including LGBTI+ young people.

Clitoral surgery on minors: an interview study with clinical experts of differences of sex development

OBJECTIVES

Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families.

DESIGN

Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis.

SETTING

Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development.

PARTICIPANTS

Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample.

RESULTS

All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions.

CONCLUSIONS

If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.

Moving intersex/DSD rights and care forward: Lay understandings of common dilemmas

When sex characteristics develop in ways that do not conform to binary models, dilemmas arise regarding how to understand the situation and what terminology to use to describe it. While current medical nomenclature suggests that it should be understood as a disorder of sex development (DSD) prompting medical responses, many describe intersex as a human variation in sexed embodiment that should be protected under discrimination laws. These opposing perspectives suggest different principles to employ in responding to dilemmas about gender assignment, early genital surgery and full disclosure of medical information. In this discursive psychological study, we explore how lay people, without prior knowledge or experience of intersex/DSD, make sense of these dilemmas and the underpinning discourses giving rise to how they talk about these situations. By using the discursive framework of ideological dilemmas, we analyse how people make sense of sex and gender (as binary or non-binary), how they deal with difference (as problematic or not), and how they understand who is in a position to make decisions in such situations. We conclude that engaging with dilemmas in-depth is more constructive than favouring one principle over others in moving social science research, reflexive clinical practice, and wider political debates on intersex/DSD forward.