Shaping parents: impact of contrasting professional counseling on parents' decision making for children with disorders of sex development

Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention

BACKGROUND

Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication.

AIM

We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH.

METHODS

Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children).

OUTCOMES

Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups.

RESULTS

For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function.

CLINICAL IMPLICATIONS

Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions.

STRENGTHS AND LIMITATIONS

This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care.

CONCLUSION

Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.

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.

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.

A survey of healthcare professionals' perceptions of the decisional needs of parents with an infant born with a disorder/difference of sex development

INTRODUCTION

Parents of infants born with differences in sex development (DSD) face many difficult decisions. As part of a larger project designed to develop educational interventions to promote shared decision making, this study assessed healthcare professionals' (HCPs) perceptions of parental decision-making needs when an infant is born with a DSD.

METHODS

A cross-sectional web-based survey following the Ottawa Decision Support Framework was conducted in two waves, between October 2020 and June 2022. Survey domains included: common DSD decisions, indicators of parents' decisional needs, and resources and approaches to support parental decision making. Eligible participants were HCPs working within interprofessional pediatric DSD centers in the USA. Up to three reminders were sent. Descriptive analysis was conducted.

RESULTS

71 HCPs participated; most (>90%) reported parents experience signs of decisional conflict including feeling unsure, worrying about what could go wrong, and fear of choosing a "wrong," irreversible option. The majority (90%) reported parents experience strong emotions interfering with their receptivity to information or deliberation. The majority (>70%) identified inadequate parental knowledge of the DSD as a barrier to decision making, coupled with information overload (>90%). HCPs rated several factors as "very" important, including: parents having information on benefits, harms, and other features of options (93%), having information about all the available options (87%), and having access to providers to discuss the options (84%). Providers endorsed using a variety of approaches to support parents' decision making; however, access to decision aids was not universally rated as highly important (very, 44%; somewhat, 46%; a little, 10%).

IMPLICATIONS

Overall, HCPs expressed favorable attitudes toward supporting active parental participation in medical decision making. Opportunities for enhanced support of shared decision making included: a) recognizing and addressing parental emotional distress and informational overload at a time when parents need to consider complex options for their infant or young child; and b) the need for HCPs to encourage values clarification in decision-making encounters with parents.

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.

Opportunities and challenges with the German act for the protection of children with variations of sex development

In May 2021, the German parliament passed a long-debated law to protect children with variations of sex development/sex characteristics from medically unnecessary surgeries until they are old enough to decide for themselves. This law joins similar laws passed in other countries in recent years and recognizes the rights of people with variations of sex development to self-determination and bodily autonomy. In this article, we discuss the notion of bodily autonomy and examine details of the German legislation in the context of psychosocial care. We focus on the following questions: (1) How may the law help to preserve the genital integrity and future bodily autonomy of newborns with variations of sex development (VSD)? (2) What are the opportunities and challenges of this law? (3) What strategies are needed to implement the law in ways that include medical professionals' knowledge and skills, parental cooperation, and protection for the genital integrity as well as the future genital autonomy of newborns with VSD? We make two main arguments. On the one hand, this law has created a space for a new discourse and discussion on VSD in German society and enables the "wait and see" approach. This approach challenges the traditional "psychosocial emergency" policy aimed at quickly "repairing" atypical genitalia. On the other hand, the law is characterized by significant challenges. For example, it does not address the meaning of bodily autonomy in the context of newborns and their families with VSD, and it overlooks the important distinction between genital appearance, genital function, and gender identity. We offer various educational strategies that can be implemented with different target groups in Germany to meet these challenges and ensure the adequate implementation of this law.

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.

"Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature

The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.

Diagnosis of DSD in Children—Development of New Tools for a Structured Diagnostic and Information Management Program within the Empower-DSD Study

Background: Current recommendations define a structured diagnostic process, transparent information, and psychosocial support by a specialized, multi-professional team as central in the care for children and adolescents with genital variations and a suspected difference of sex development (DSD). The active involvement of the child and their parents in shared decision-making should result in an individualized care plan. So far, this process has not been standardized. Methods: Within the Empower-DSD study, a team of professionals and representatives of patient advocacy groups developed a new diagnostic and information management program based on current recommendations and existing patient information. Results: The information management defines and standardizes generic care elements for the first weeks after a suspected DSD diagnosis. Three different tools were developed: a guideline for the specialized multiprofessional team, a personal health record and information kit for the child with DSD and their family, and a booklet for medical staff not specialized in DSD. Conclusions: The new information management offers guidance for patients and professionals during the first weeks after a DSD diagnosis is suspected. The developed tools’ evaluation will provide further insight into the diagnostic and information-sharing process as well as into all of the involved stakeholders’ needs.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]

Hintergrund

Die konservative und chirurgische Behandlung von Kindern ist in der urologischen Facharztweiterbildung fest verankert und stellt eine Kernkompetenz der urologischen Versorgung dar. Berufspolitisch wird seit vielen Jahren ein zunehmender Verlust dieses Schwerpunkts befürchtet. Ziel dieser Studie ist es, reale Fallzahlen und eine mögliche Dynamik in der Verteilung kinderurologischer Eingriffe auf die Fachabteilungen für Urologie und Kinderchirurgie in Deutschland zu prüfen.

Material und Methoden

Als Index-Eingriffe definierten wir Operationen des Hodenhochstands, der Hypospadie und des vesikoureteralen Refluxes (VUR). Mithilfe der Software reimbursement.INFO (RI Innovation GmbH, Hürth) werteten wir die öffentlich zugänglichen Qualitätsberichtsdaten der deutschen Krankenhäuser von 2006 bis 2019 aus und wiesen sie den entsprechenden Fachrichtungen zu.

Ergebnisse

Die Orchidopexie erfolgt häufiger in der Urologie, wohingegen die Hypospadiekorrektur und die operative Therapie des VUR häufiger in der Kinderchirurgie durchgeführt werden. Anteilig zeigte sich für die Orchidopexie und die operative Refluxtherapie keine relevante Verschiebung zwischen urologischen und kinderchirurgischen Kliniken im Untersuchungszeitraum. Bei den Hypospadiekorrekturen nimmt der Anteil der Operationen in kinderchirurgischen Einheiten zu (p < 0,0001). In der Kinderchirurgie erfolgen 84–93 % der analysierten Eingriffe in High-volume-Abteilungen während dieser Anteil in der Urologie bei 56–73 % liegt. Insbesondere die operative Refluxtherapie in der Urologie erfolgt zu einem hohen Anteil als Gelegenheitseingriff (30 % „very low volume“).

Schlussfolgerung

Die Qualitätsberichtsdaten ermöglichen die Erfassung der Fallzahlen und die Analyse der Verteilung zwischen Urologie und Kinderchirurgie in Deutschland. Dabei ist für die Hypospadiekorrektur eine relevante Verschiebung in Richtung der Kinderchirurgie zu beobachten. Die Ursachen und möglichen berufspolitischen Konsequenzen dieser ersten Erhebung sind komplex und bedürfen weiterer Analysen.

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.

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.

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.

Do parents really know best? Informed consent to sex assigning and 'normalising' treatment of minors with variations of sex characteristics

This paper aims to explore how pervasive constructions regarding a person's sex and gender identity in society and law limit the human rights of persons with variations of sex characteristics. Societal culture promulgates a binary (male/female) gender ideal which includes standards of normality for our bodies. People who do not easily fit these culturally constructed norms, such as persons with variations of sex characteristics, encounter numerous difficulties. The legal conceptualisation of 'sex' according to the binary maintains the medicalisation of variations of sex characteristics and reinforces the focus on sex 'normalising' treatment of children who are too young to provide their informed consent. The paper makes use of Belgium as an illustration. Not only is comprehensive legal research concerning variations of sex characteristics absent in Belgium, but the country has also been responsive to human rights claims regarding sexual identity in recent years. With regards to the sex assigning or 'normalising' treatment of persons with variations of sex characteristics, this paper argues that by accepting the substitution of the child's informed consent for the opinion of the legal representative in the absence of urgent medical necessity, Belgian law fails to protect the former's right to bodily integrity and best interests.

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.

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.

Parental understanding of crucial medical jargon used in prenatal prematurity counseling

BACKGROUND

Parent-clinician shared decision making is the recommended model for the care of premature infants; thus, clinicians provide prenatal prematurity counseling to parents in the event of a mother's hospitalization for premature birth. However, parental understanding of medical jargon commonly used during prematurity counseling is unknown.

METHODS

Within an overall research agenda to develop and test an educational aid for prenatal prematurity education, we designed the Parental Knowledge of Premature Birth questionnaire. To evaluate parental comprehension of the medical jargon contained within the questionnaire, we conducted cognitive interviews, a formal method for evaluating comprehension and response to questionnaire items. Parents were recruited from a Level IV Neonatal Intensive Care Unit; purposeful recruitment ensured diversity with respect to gender, race, literacy level, and child's gestational age. Data collection and analysis followed standard qualitative methods for cognitive interviewing. We report on the insights gained from these cognitive interviews regarding parental understanding of crucial medical jargon commonly used during prenatal prematurity counseling.

RESULTS

Participants included 10 women and 6 men who ranged in age from 23 to 38 years and represented Black/African-American (38%), Asian (6%), and white (56%) backgrounds. Five participants (31%) had less than a high school education or reading level below 9th grade (Wide Range Achievement Test version 4 reading subtest). In the first round of interviews, parents of all education and literacy levels had difficulty with medical jargon commonly used in prematurity counseling. Terms that parents found difficult to understand included "gestational age", "mild or no developmental problems", and "neonatologist". Modified terms tested in a second round of interviews showed improved comprehension.

CONCLUSION

Cognitive interviews provided empirical testing of parental understanding of crucial medical jargon and highlighted that language commonly used during prenatal prematurity counseling is not understood by many parents. For parents to participate in shared decision making, plain language should be used to maximize their understanding of medical information.

A shared decision-making tool for individuals living with complete androgen insensitivity syndrome

Reports exist regarding a gradual approach to the care of patients with differences of sexual development. Each patient and family have different values and styles of learning that have to be taken into account. The goals of care should include education about the condition, counseling of the patient and family, and a complete outlining of treatment options. Motivated by a call from the 2010 Health Reform Law for the use of shared decision-making tools and the emphasis placed on these issues by the DSD Consensus Statement, we sought to develop and implement such tools for the DSD population.^1-3 Thus, we developed an organized checklist for providers to share with a patients and families affected by CAIS, beginning with the initial visit. The development of the document enlisted input from physicians, clinical coordinator, advocacy groups and affected individuals. It allows providers to explain the process of care and develop a plan for delivery of that care over multiple visits spanning six months or more. The checklist is divided into five sections: 1) An overview addressing how much information is desired and in what manner the patient prefers to obtain information; 2) A preferred words list so that the patient can choose nomenclature that is most comfortable; 3) A list of topics to review over the course of multiple visits; 4) A list of questions to be answered by the providers or other resources over time, and; 5) A list of concerns to be addressed before surgical intervention is considered. An organized approach to long-term delivery of compassionate care and accurate information can be facilitated for patients with CAIS by the use of a shared decision-making checklist. Documentation of the care delivery process can stimulate referral to peer support and promote fully informed consent for treatment decisions. The use of the checklist should encourage trust in the provider, as well as aid in identifying and addressing stressors for the patient and family. The checklist will be updated and revised as new treatments and advanced technology emerges.

Impact of specialized pediatric palliative care programs on communication and decision-making

OBJECTIVE

To summarize and analyze the impact of specialized pediatric palliative care (SPPC) programs on communication and decision-making for children with life-threatening conditions.

METHODS

Our search strategy covered MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Scopus, and Embase through September 2018.

RESULTS

We reviewed 13 studies analyzing the impact of SPPC programs on communication and decision-making using a wide range of outcome indicators. Study quality was poor in 58% of included papers. SPPC programs improved communication and decision-making between families and healthcare professionals (HCPs), within and between families, and among HCPs.

CONCLUSION

SPPC programs generally support and improve communication and decision-making for children with life-threatening conditions, their families and associated HCPs. Families referred to an SPPC program had more discussions with HCPs on a broad variety of topics. However, data on communication with children, siblings, and other family members was scarce and of poor quality.

PRACTICE IMPLICATIONS

More research on SPPC program efficacy is needed from the perspective of the ill child, as well as about barriers to end-of-life discussions and the specific aspects of SPPC programs responsible for improving outcomes.

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.

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

Intersex or diverse sex development (dsd) can be conceptualized as an aspect of bodily diversity that has particular psychosocial implications. This is a review of psychosocial health care literature, published from 2007 to 2017, focusing on the well-being of people with a diagnosis relating to sex development. The analysis I offer here takes a critical psychological approach, questioning norms and taken-for-granted assumptions. This approach works from the understanding that how we know and how we talk about a phenomenon affects people in material and life-changing ways. This article offers recommendations concerning health care communication, the importance of taking time for emotion, and the process of building supportive relationships. The research reviewed provides clear evidence of psychosocial harm that is done through genital intervention and evidence that parents do not routinely give fully informed consent before their children undergo treatment. Finally, I highlight key points and recommendations for health professionals, indicating how psychosocial professionals can contribute to health care and well-being in the context of dsd when appropriately resourced and trained.

Does Patient-centered Care Change Genital Surgery Decisions? The Strategic Use of Clinical Uncertainty in Disorders of Sex Development Clinics

Genital surgery in children with ambiguous or atypical genitalia has been marred by controversies about the appropriateness and timing of surgery, generating clinical uncertainty about decision making. Since 2006, medical experts and patient advocates have argued for putting the child's needs central as patient-centered care. Based on audio recordings of 31 parent-clinician interactions in three clinics of disorders of sex development, we analyze how parents and clinicians decide on genital surgery. We find that clinicians and parents aim for parent-centered rather than infant-centered care. Parents receive ambivalent messages about surgery: while clinicians express caution, they also present the surgery as beneficial. We examine how parents and clinicians reach agreement about surgery-differentiating parents who push strongly for surgery from parents who do not express any preconceived preferences about surgery and parents who resist surgery. We conclude that clinicians use clinical uncertainty about surgery strategically to direct parents toward perceived clinically appropriate decisions.

Shaping parents, shaping penises: How medical teams frame parents' decisions in response to hypospadias

INTRODUCTION

Psychological research provides insights into how parents approach medical decisions on behalf of children. The medical decision of concern here is the surgical alteration of a hypospadic penis, whose urethral opening does not appear at the tip. Hypospadias surgery is routinely carried out in infancy, despite criticism by international organizations concerned about children's rights. The focus of this study is on the framing of hypospadias surgery.

OBJECTIVES

The objective was to examine how health professionals frame hypospadias and hypospadias surgery in medical and non-medical ways.

DESIGN

This was a qualitative study designed to build on the experimental research of Streuli et al. who investigated how medical versus non-medical information affects decision-making about non-essential childhood genital surgery.

METHODS

Semi-structured interviews were undertaken with 32 health professionals. Theoretically informed thematic analysis was used to examine how health professionals talk about hypospadias surgery and about supporting parents to make treatment decisions.

RESULTS

The analysis suggests that medical professionals' engagement with parents underestimates the effect of framing in influencing parental decisions about hypospadias surgery. Some psychological specialists in this area are actively framing hypospadias in ways that enable some parents to choose a non-medical pathway. Psychologically informed ways of talking about a child's genital difference focus on psychological qualities, including affect, well-being, and unconditional positive regard.

CONCLUSIONS

The best interests of children with hypospadias may well be served when psychological pathways are highlighted, providing opportunities to support the flourishing of children whose genital appearance raises the question of medical intervention. Statement of Contribution What is already known on this subject? Framing significantly affects medical decision-making in ways that people typically fail to perceive. Parents frequently consent to non-essential hypospadias (penile) surgery for their sons, despite the risks and ethical concerns. What does this study add? Medical teams could do more to consider framing when counselling parents about their son's hypospadias. Psychological specialists can help parents to frame their son's penile difference in terms of well-being and love. The best interests of children with hypospadias may be served by highlighting psychological care pathways.

Vaginal Construction and Treatment Providers' Experiences: A Qualitative Analysis

STUDY OBJECTIVE

To investigate specialist clinicians' experiences of treating vaginal agenesis.

DESIGN

Semi-structured interviews.

SETTING

Twelve hospitals in Britain and Sweden.

PARTICIPANTS

Thirty-two health professionals connected to multidisciplinary teams (MDTs) including medical specialists and psychologists.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Theoretical thematic analysis of recorded verbatim data.

RESULTS

The gynecologist and psychologist interviewees share certain observations including the importance of psychological readiness for and appropriate timing of treatment. Three overlapping themes are identified in our theoretical analysis of the MDT clinicians' talk: (1) the stigma of vaginal agenesis and the pressure to be "normal" can lead patients to minimize the time, effort, physical discomfort, and emotional cost inherent in treatment. (2) Under pressure, treatment might be presented to patients with insufficient attention to the potential psychological effect of the language used. Furthermore, the opportunity to question what is "normal" in sex is generally not taken up. It can be challenging to help the women to transcend their medicalized experiences to come to experiencing their bodies as sexual and enjoyable. (3) The reality of treatment demands, which are not always adequately processed before treatment, can lead to discontinuation and even disengagement with services.

CONCLUSION

The MDT clinicians in this study emphasized the importance of psychological input in vaginal construction. However, such input should proactively question social norms about how women's genitalia should appear and function. Furthermore, rather than steering patients (back) to treatment, the entire MDT could more explicitly question social norms and help the women to do the same. By shifting the definition of success from anatomy to personal agency, the clinical focus is transformed from treatment to women.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Coping With Diverse Sex Development: Treatment Experiences and Psychosocial Support During Childhood and Adolescence and Adult Well-Being

Objectives

The purpose of this exploratory, retrospective, and correlational study was to examine the relationships between childhood treatment experiences, parental care, and social support, and outcome in adults with different diverse sex development (DSD).

Methods

The data of 69 participants from an exploratory questionnaire were collected in a retrospective German study.

Results

The majority received medical treatment in relation to their DSD during childhood and adolescence. Seventy percent reported having had a best friend and 29% a confidant during childhood. Sixty-one percent showed clinically relevant psychological distress, and 45% reported suicidal thoughts at least at one point in their lives. Quality of parental care and having had a best friend correlated positively with adult outcome, whereas treatment experiences correlated with aspects of impaired adjustment.

Conclusions

Social support and DSD-related treatment experiences appear to have an impact on adult well-being. Appropriate psychosocial care including peer-to-peer support should be made available to children with DSD and their families.

From Knowing Nothing to Knowing What, How and Now: Parents' Experiences of Caring for their Children With Congenital Adrenal Hyperplasia

Objective

This study investigates various kinds of knowing that European parents use when caring for their children with congenital adrenal hyperplasia (CAH).

Methods

Semi-structured qualitative interviews with 20 parents of 22 children with CAH.

Results

Parents emphasized the importance of knowing what CAH is and what support their child needs, but also knowing how to cope and make sense of the new situation, how to attend to their child's medical needs as well as how to talk to their child. Parents also reported challenges related to connecting with their social network, experiences of emergency care, and how to help their children become independent. These challenges require knowing now : being able to respond appropriately to unique circumstances.

Conclusions

Parents experience diverse challenges that may moderate the effects of the diagnosis on children's well-being. Parenting children with CAH requires the development of knowing that goes beyond medical information.

Recommendations for the Establishment of Disorders/Differences of Sex Development Interdisciplinary Care Clinics for Youth

PURPOSE

Provide recommendations for the development of an interdisciplinary care (IDC) clinic for the treatment of youth with disorders/differences of sex development (DSD). DSD consist of a group of complex congenital medical disorders in which the development of chromosomal, gonadal, or anatomical sex is atypical. Youth with DSD require care from multiple specialized healthcare disciplines, including several medical specialties, surgery, nursing, and mental health.

METHOD

Recommendations are based on an interdisciplinary care clinic model that allows for a team of relevant professionals who share knowledge, ideas, and responsibility of care. The framework established in this article is based largely on experiences at an established DSD clinic, as well as observations of multiple clinics across the United States.

RESULTS

Preliminary outcome data on clinic adherence to treatment protocol under an IDC model are provided.

CONCLUSIONS

To meet the diverse healthcare needs of youth with DSD, comprehensive care clinics are recommended; however, few such clinics exist in the United States. Establishing new comprehensive DSD clinics can be challenging due to the highly unique treatment of DSD, but the current paper expands the literature available to guide clinic development in the United States.

Between Concealing and Revealing Intersexed Bodies: Parental Strategies

Parents of intersex children are perceived in many studies as hopeless, highly dependent on the medical system, and as gate keepers of normative gendered bodies. In this article, we challenge these perceptions and argue that parents of intersex children are problematically positioned between their children's needs for care and well-being and the socialmedical forces that aim to "normalize" them. Their in-between position leads them to establish different parental strategies within and outside of traditional sex/gender norms. We focus on three intertwined parental strategy frameworks: bodily dialogue, sex/gender framing, and concealing/revealing practices, and describe how, in each of these strategic frameworks, the parents maneuver, act in accordance with or against, react to, and challenge the medical system, social interactions, and the sex/gender paradigm. This is a comparative study based on narrative interviews with 22 parents of intersex children in Germany and Israel.

Legal, ethical, and human rights considerations for physicians treating children with atypical or ambiguous genitalia

Some governments, human rights organizations, intersex organizations, and doctors have called for a moratorium on genital and gonadal surgeries for infants born with atypical or ambiguous genitalia. Moratorium supporters believe that the surgeries carry physical and emotional risks, the psychosocial benefits of these procedures have not been proven, and the surgeries violate the patients׳ fundamental human rights if they are performed before these patients can provide informed consent. Given these calls for a moratorium, treatment teams must determine how to treat their patients and how to counsel their patients׳ parents. This article examines the treatment teams׳ ethical and legal responsibilities and provides advice for treatment teams to follow that will protect their patients and their practices.

Negotiating intersex: A case for revising the theory of social diagnosis

The theory of social diagnosis recognizes two principles: 1) extra-medical social structures frame diagnosis; and 2) myriad social actors, in addition to clinicians, contribute to diagnostic labels and processes. The relationship between social diagnosis and (de)medicalization remains undertheorized, however, because social diagnosis does not account for how social actors can also resist the pathologization of symptoms and conditions-sometimes at the same time as they clamor for medical recognition-thereby shaping societal definitions of disease in different, but no less important, ways. In this article, we expand the social diagnosis framework by adding a third principle, specifically that 3) social actors engage with social structures to both contribute to, and resist, the framing of a condition as pathological (i.e. medicalization and demedicalization). This revised social diagnosis framework allows for the systematic investigation of multi-directional, dynamic processes, formalizing the link between diagnosis and (de)medicalization. It also responds to long-standing calls for more contextualized research in (de)medicalization studies by offering a framework that explicitly accounts for the social contexts in which (de)medicalizing processes operate. To showcase the utility of this revised framework, we use it to guide our analyses of a highly negotiated diagnosis: intersex.

Follow-up of psychological outcomes of interventions in patients diagnosed with disorders of sexual development: A systematic review

The objective of this study was to perform a systematic review of articles that followed up the psychological outcomes of interventions in patients with disorders of sexual development. The analysis focused on the methodological quality of the studies and the assumptions on the evaluation of the intervention outcomes. The review signaled the need for better consideration about the complexity of intersexuality and for a shift from the anatomical/functional/aesthetic to the subjective outcomes related to patient’s quality of life. Furthermore, it is suggested that the interventions should be better investigated, given the lack of evidence for the necessity of early procedures.

Subjective need for psychological support (PsySupp) in parents of children and adolescents with disorders of sex development (dsd)

Disorders/diversity of sex development (dsd) is an umbrella term for congenital conditions often diagnosed within childhood. As most parents are unprepared for this situation, psychological support (PsySupp) is recommended. The aim of this study was to analyse the extent to which parents express a need for PsySupp. Three hundred twenty-nine parents of children with dsd were included; 40.4 % of the parents indicated to have a need for PsySupp, only 50 % of this group received it adequately. The diagnoses partial gonadal dysgenesis, partial androgen insensitivity syndrome (pAIS) and disorders of androgen synthesis are associated with a high need for PsySupp in parents (54, 65, and 50 %). Sex assignment surgery neither reduced nor increased the need for PsySupp. Taking a picture, radiography, laparoscopy, gonadal biopsy, gonadectomy and hormonal puberty induction are associated with a high need for PsySupp. There was no association between the need for PsySupp and the parents' perception of the appearance of the genitalia.

CONCLUSION

Having a child with dsd is associated with a high need for PsySupp in parents. In particular, parents of children with XY-dsd with androgen effects other than hypospadias expressed a high need of PsySupp. PsySupp for parents should be an obligatory part of interdisciplinary care to reduce fears and concerns. What is known • In parents, having a child with dsd provokes insecurities and fears. Hence, psychological support is recommended as part of the interdisciplinary care. What is new • This is the first study investigating the subjective need for psychological support in a large sample of parents of children with dsd in Germany. We present data on the subjective need for psychological support of the parents, related diagnoses and factors, which should be considered in psychological counselling.

Multidisciplinary care for individuals with disorders of sex development

PURPOSE OF REVIEW

Recommendations regarding the care of individuals with disorders of sex development include that care be provided by multidisciplinary teams. This article will discuss team composition and function as well as the role of the gynecologist and barriers to such care.

RECENT FINDINGS

Many barriers to multidisciplinary care exist, but recent reports stress the roles of different team members as well as tools for planning and implementation of such a team that may help to overcome such barriers. All current recommendations include the participation of a gynecologist in the disorders of sex development team. Gynecologists are in the unique position to continue to provide care as these individuals mature into adulthood.

SUMMARY

Multidisciplinary care for patients with disorders of sex development is recommended and gynecologists provide unique expertise.