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Khorashad BS, Gardner M, Lee PA, Kogan BA, Sandberg DE. Recommendations for 46,XY Disorders/Differences of Sex Development Across Two Decades: Insights from North American Pediatric Endocrinologists and Urologists. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2939-2956. [PMID: 39039338 PMCID: PMC11335971 DOI: 10.1007/s10508-024-02942-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/10/2024] [Accepted: 06/13/2024] [Indexed: 07/24/2024]
Abstract
Clinical decision-making for individuals with 46,XY disorders/differences of sex development (DSD) remains unsettled and controversial. The North American DSD Clinician Survey examines the recommendations of a large group of clinical specialists over the last two decades. Active members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology were invited to respond to a web-based survey at three different timepoints: 2003-2004 (T1), 2010-2011 (T2), and 2019-2020 (T3). Data from 429 participants in T1, 435 in T2, and 264 in T3 were included in this study. The participants were presented with three XY newborn clinical case scenarios-micropenis, partial androgen insensitivity syndrome, and iatrogenic penile ablation-and asked for clinical management recommendations. The main outcomes assessed included the recommended gender of rearing, surgical decision-maker (parent or patient), timing of genital surgery, and age at which to disclose medical details and surgical history to the patient. For all scenarios, the overwhelming majority recommended rearing as male, including a significant increase across timepoints in those recommending a male gender of rearing for the infant with penile ablation. The proportions recommending female gender of rearing declined significantly across timepoints. In general, most recommended parents (in consultation with the physician) serve as surgical decision-makers, but these proportions declined significantly across timepoints. Recommendations on the timing of surgery varied based on the patient's gender and type of surgery. There has been a shift in recommendations away from the "optimal gender policy" regarding gender of rearing and surgical interventions for patients with XY DSD.
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Affiliation(s)
- Behzad Sorouri Khorashad
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA
| | - Melissa Gardner
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI, 48109-2600, USA.
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
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DeLone AM, Fisher RS, Traino KA, Basile NL, Buchanan CL, Cheng EY, Poppas DP, Baraldi AN, Wisniewski AB, Mullins LL. Exploratory factor analysis of the Illness Intrusiveness Rating Scale for parents of children with atypical genital appearance due to differences of sex development (DSD). J Pediatr Psychol 2024; 49:482-490. [PMID: 38578612 PMCID: PMC11258802 DOI: 10.1093/jpepsy/jsae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE Illness intrusiveness refers to the subjective cognitive appraisal of a chronic health condition interfering in daily, valued activities and may be highly relevant for parents of children with atypical genital appearance due to differences of sex development (DSD). However, a measure of illness intrusiveness has not been validated for this population. The current study aimed to evaluate the factor structure of the Illness Intrusiveness Scale for Parents (IIS-P) and examine convergent validity. METHODS Participants included 102 parents (Mage = 33.39 years, SD = 6.48; 58% mothers) of 65 children (<2 years old) diagnosed with DSD participating in a larger, longitudinal study. Parents completed the IIS-P as well as self-report measures of stigma, and anxious and depressive symptoms. An exploratory factor analysis (EFA) was conducted. RESULTS EFA results supported a 1-factor intrusiveness solution (α = .93), as well as a 2-factor solution measuring intrusiveness on daily living (α = .92) and community connectedness (α = .85). The 1-factor solution and both factors of the 2-factor solution demonstrated significant convergent validity with stigma as well as anxious and depressive symptoms. CONCLUSIONS Support emerged for both 1- and 2-factor solutions of the IIS-P in parents of children with DSD. The decision to evaluate illness intrusiveness as a total score or to examine the subscales of daily living and community connectedness should be tailored to the unique aims of researchers and clinicians. Future research should conduct a confirmatory factor analysis with both 1- and 2-factor models with larger, more diverse samples of caregivers.
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Affiliation(s)
- Alexandra M DeLone
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Rachel S Fisher
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Nathan L Basile
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, United States
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, United States
| | - Dix P Poppas
- James Buchanan Brady Department of Urology, Komansky Children’s Hospital, New York Presbyterian Hospital-Weill Cornell Medicine, New York, United States
| | - Amanda N Baraldi
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
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Haller M, Yin Y, Haller G, Li T, Li Q, Lamb LE, Ma L. Streamlined identification of clinically and functionally relevant genetic regulators of lower-tract urogenital development. Proc Natl Acad Sci U S A 2024; 121:e2309466121. [PMID: 38300866 PMCID: PMC10861909 DOI: 10.1073/pnas.2309466121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/18/2023] [Indexed: 02/03/2024] Open
Abstract
Congenital anomalies of the lower genitourinary (LGU) tract are frequently comorbid due to genetically linked developmental pathways, and are among the most common yet most socially stigmatized congenital phenotypes. Genes involved in sexual differentiation are prime candidates for developmental anomalies of multiple LGU organs, but insufficient prospective screening tools have prevented the rapid identification of causative genes. Androgen signaling is among the most influential modulators of LGU development. The present study uses SpDamID technology in vivo to generate a comprehensive map of the pathways actively regulated by the androgen receptor (AR) in the genitalia in the presence of the p300 coactivator, identifying wingless/integrated (WNT) signaling as a highly enriched AR-regulated pathway in the genitalia. Transcription factor (TF) hits were then assayed for sexually dimorphic expression at two critical time points and also cross-referenced to a database of clinically relevant copy number variations to identify 252 TFs exhibiting copy variation in patients with LGU phenotypes. A subset of 54 TFs was identified for which LGU phenotypes are statistically overrepresented as a proportion of total observed phenotypes. The 252 TF hitlist was then subjected to a functional screen to identify hits whose silencing affects genital mesenchymal growth rates. Overlap of these datasets results in a refined list of 133 TFs of both functional and clinical relevance to LGU development, 31 of which are top priority candidates, including the well-documented renal progenitor regulator, Sall1. Loss of Sall1 was examined in vivo and confirmed to be a powerful regulator of LGU development.
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Affiliation(s)
- Meade Haller
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO63110
| | - Yan Yin
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO63110
| | - Gabe Haller
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO63110
| | - Tian Li
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO63110
| | - Qiufang Li
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO63110
| | - Laura E. Lamb
- Department of Urology, William Beaumont School of Medicine, Oakland University, Rochester, MI48309
| | - Liang Ma
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO63110
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Moyer DN, Suorsa-Johnson KI, Weidler EM, Ernst MM. Information sharing in differences of sex development: The creation of a caregiver-support tool. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2023; 41:256-264. [PMID: 36066861 PMCID: PMC9985666 DOI: 10.1037/fsh0000724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Social support can be a protective factor against the negative mental health outcomes experienced by some parents and caregivers of children with differences of sex development (DSD). However, established social support networks can be difficult to access due to caregiver hesitancy to share information with others about their child's diagnosis. Health care providers in the field of DSD, and particularly behavioral health providers, are well positioned to help caregivers share information with the important people in their lives in order to access needed social support. This article summarizes the development of a clinical tool to help clinicians facilitate discussions regarding information sharing with caregivers of children with DSD. METHOD Members of the psychosocial workgroup for the DSD -Translational Research Network completed a survey about their experiences facilitating information sharing discussions with caregivers of children with DSD and other health populations. The results of this survey were used to develop a clinical tool using ongoing iterative feedback from workgroup members, based on principles of user-centered design and quality improvement. RESULTS Workgroup members consider information sharing an important aspect of working with caregivers of children with DSD. Additional resources and tools were identified as potentially helpful to these discussions. DISCUSSION The DSD Sharing Health Information Powerfully-Team Version (SHIP-T) is a resource tool for DSD health care team members to utilize in hospital and ambulatory settings to help caregivers of children with DSD share information with their social support networks. The final SHIP-T is included in this article. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital
- Accord Alliance, USA
| | - Michelle M. Ernst
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center
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Fisher RS, Datillo TM, Baskin LS, Buchanan CL, Cheng EY, Kolon T, Nokoff NJ, Poppas DP, Reyes KJ, Mullins LL, Wisniewski AB. Decisional Regret Among Caregivers of Infants with Differences of Sex Development Reared as Male. J Dev Behav Pediatr 2023; 44:e225-e230. [PMID: 36729523 PMCID: PMC10065892 DOI: 10.1097/dbp.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 10/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Differences of sex development (DSD) are congenital conditions in which individuals are discordant in their chromosomal, phenotypic, and/or gonadal sex. Treatment of DSD can involve surgical intervention to external genitalia to make anatomy seem male-typical (i.e., male genitoplasty). Caregiver-perceived decisional regret regarding young boys with DSD was explored quantitatively and qualitatively. METHOD Participants (N = 39) were caregivers of infants (N = 23) diagnosed with DSD (mean age = 8.9 months, standard deviation = 5.9 months) reared male participating in a longitudinal investigation of psychosocial outcomes. Qualitative data were collected at 6 to 12 months after baseline enrollment to evaluate caregiver decision-making corresponding to levels of regret concerning their child's treatment. All but one infant received genital surgery before caregiver reporting on their decisional regret. Quantitative exploratory analyses evaluated longitudinal predictors of decisional regret at 6 to 12 months. RESULTS When completing a write-in item inquiring about decision-making and potential regret, most caregivers (n = 16, 76%) reported that their child's genital surgery was their first medical decision. Two caregivers referenced gender assignment as a decision point. One-third of caregivers reported some level of decisional regret (33%), with 67% reporting no regret. No hypothesized predictors of decisional regret were statistically significant. CONCLUSION Many caregivers of infants with DSD reared male view genital surgery as a first health care decision. Approximately one-third of caregivers reported some level of decisional regret. Further research is warranted to explore long-term decisional regret; it will be particularly important to investigate the decisional regret of patients with DSD.
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Affiliation(s)
- Rachel S. Fisher
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Taylor M. Datillo
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Laurence S. Baskin
- University of California San Francisco Medical Center, Department of Urology, San Francisco, CA, USA
| | - Cindy L. Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO, USA
| | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL, USA
| | - Thomas Kolon
- Children’s Hospital of Philadelphia, Division of Urology, Philadelphia, PA, USA
| | - Natalie J. Nokoff
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Division of Endocrinology, Aurora, CO, USA
| | - Dix P. Poppas
- New York Presbyterian Weill Cornell Medicine, Department of Urology, Komansky Children’s Hospital, New York, NY, USA
| | - Kristy J. Reyes
- Cook Children’s Medical Center, Department of Pediatric Urology, Fort Worth, TX, USA
| | - Larry L. Mullins
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Amy B. Wisniewski
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
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Verma P, Sharma S, Kaur S, Rohilla L, Malhi P, Dayal D. Evaluation of a nurse-led counselling intervention on selected outcome variables for parents of children with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2023; 36:248-254. [PMID: 36727475 DOI: 10.1515/jpem-2022-0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/15/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Long-term care of children with congenital adrenal hyperplasia (CAH) has psycho-social implications for parents. Experts recommend a customized educational program for parents to facilitate their psychological adaptation and improve disease management. Such educational programs often provided by nurse counsellors are well evaluated in developed countries. There is a dearth of data on nurse-led counselling in the context of less developed countries. We aimed to evaluate the effect of a nurse-led counselling intervention on various psycho-social outcomes among parents of children with CAH. METHODS Fifty consecutive parents of children with CAH attending an outpatient clinic at a tertiary-care teaching hospital were enrolled. Parents' stress level, stigma, knowledge, practices, and treatment adherence were assessed by using Cohen's Perceived Stress Scale (PSS), DSD Stigma scale, and HILL-Bon Medication Adherence Scale (HB-MAS). Three educational counselling sessions were conducted within a month's gap, using PowerPoint presentations and a booklet. Assessment of outcomes was done at baseline and at the end of the third session. RESULTS At baseline, the majority (90%) of the parents had moderate stress. Half of the parents had mild and the rest had moderate stigma. After the intervention, the majority (94%) of parents had shifted to mild levels of stress and stigma. At baseline, 86% of the parents had poor knowledge about the disease whereas post-intervention, 80% were having good knowledge. Disease management practices and treatment adherence also improved after the intervention. CONCLUSIONS Nurse-led counselling was effective in reducing psycho-social problems, increasing knowledge, as well as improving practices and treatment adherence.
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Affiliation(s)
- Poonam Verma
- National Institute of Nursing Education, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Sunita Sharma
- National Institute of Nursing Education, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Sukhwinder Kaur
- National Institute of Nursing Education, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Latika Rohilla
- Endocrinology & Diabetes Unit, Department of Pediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Prahbhjot Malhi
- Endocrinology & Diabetes Unit, Department of Pediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Devi Dayal
- Endocrinology & Diabetes Unit, Department of Pediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Gardner M, Brinkman WB, Carley M, Liang N, Lightfoot S, Pinkelman K, Speiser PW, Schafer-Kalkhoff T, Suorsa-Johnson KI, VanderBrink B, Weidler EM, Wisniewski J, Stacey D, Sandberg DE. Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development. FRONTIERS IN UROLOGY 2023; 3:1089077. [PMID: 37920725 PMCID: PMC10621652 DOI: 10.3389/fruro.2023.1089077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support. Methods 34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted. Results Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information. Discussion Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.
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Affiliation(s)
- Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William B. Brinkman
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noi Liang
- Patient / parent / caregiver stakeholder partners, Denver, CO, USA
| | | | - Kendra Pinkelman
- Patient / parent / caregiver stakeholder partners, Ann Arbor, MI, USA
| | - Phyllis W. Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | | | - Brian VanderBrink
- Division of Urology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ
- Accord Alliance, USA
| | | | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
- Accord Alliance, USA
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Hegarty P, Smith A. Public understanding of intersex: an update on recent findings. Int J Impot Res 2023; 35:72-77. [PMID: 35031713 PMCID: PMC9935380 DOI: 10.1038/s41443-021-00485-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/17/2021] [Accepted: 10/14/2021] [Indexed: 11/08/2022]
Abstract
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.
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Meyer-Bahlburg HFL. Censoring Intersex Science: A Medical School Scandal. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:21-25. [PMID: 36344791 DOI: 10.1007/s10508-022-02445-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 09/16/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
A senior pediatric endocrinologist at a leading medical school in Canada has for years provided the introductory lecture on Disorders of Sex Development/Intersexuality (DSD/I) in the standard second-year course. In 2020/2021, two students complained to medical school administrators about six specific issues of intersex theory and care that were addressed in the lecture (Polychronakos, 2021). Subsequently, the administration replaced the professor with a different lecturer, thus effectively censoring the dissemination of intersex science. An overview of the status of the clinical literature on intersexuality shows that the students' critiques focus on concepts and facts that have been developed in extensive medical and sexological research over the past 50-60 years, as is shown for each of their points of critique. By censoring the professor's teaching, the medical school not only violated academic freedom, but also suppressed well-established scientific facts, kept medical students uninformed about the diverse points of view in this area of clinical management, and likely undermined future evidence-based medical and psychosocial care by these students for individuals with this type of medical condition.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
- Department of Psychiatry, Vagelos College of Physicians & Surgeons of Columbia University, New York, NY, USA.
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 674] [Impact Index Per Article: 337.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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11
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Traino KA, Roberts CM, Fisher RS, Delozier AM, Austin PF, Baskin LS, Chan YM, Cheng EY, Diamond DA, Fried AJ, Kropp B, Lakshmanan Y, Meyer SZ, Meyer T, Buchanan C, Palmer BW, Paradis A, Reyes KJ, Tishelman A, Williot P, Wolfe-Christensen C, Yerkes EB, Mullins LL, Wisniewski AB. Stigma, Intrusiveness, and Distress in Parents of Children with a Disorder/Difference of Sex Development. J Dev Behav Pediatr 2022; 43:e473-e482. [PMID: 35353771 PMCID: PMC9474682 DOI: 10.1097/dbp.0000000000001077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The impact of parent-reported stigma due to their child's disorder/difference of sex development (DSD) on parent psychosocial adjustment is poorly understood. In other pediatric populations, perceived interference of medical conditions into daily activities (i.e., illness intrusiveness ) mediates the relationship of stigma to adjustment. This study assessed relationships between parent-focused and child-focused stigma → illness intrusiveness → depressive and anxious symptoms . Exploratory analyses sought to identify patient characteristics associated with stigma. METHOD Caregivers (59 women and 43 men) of 63 children diagnosed with a DSD up to age 4 years completed measures of demographics, parent-focused and child-focused stigma, illness intrusiveness, and depressive and anxious symptoms. RESULTS Increased parent-focused and child-focused stigma were associated with increased illness intrusiveness, which, in turn, was associated with increased depressive and anxious symptoms for parents nested within dyads. Among children with DSD family histories, parents reported greater child-focused stigma. CONCLUSION Parents who experience DSD-related stigma report greater interference of their child's DSD into their daily activities, which is associated with poorer psychosocial adjustment. Findings support developing clinical interventions related to parents' perceptions of stigma and illness intrusiveness to improve parent adjustment.
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Affiliation(s)
- Katherine A. Traino
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
| | - Caroline M. Roberts
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
| | - Rachel S. Fisher
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
| | - Alexandria M. Delozier
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
| | - Paul F. Austin
- Texas Children’s Hospital, Department of Urology Houston, TX
| | - Laurence S. Baskin
- University of California San Francisco Medical Center, Department of Urology, San Francisco, CA
| | - Yee-Ming Chan
- Boston Children’s Hospital, Division of Endocrinology, and Harvard Medical School, Boston, MA
| | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL
| | - David A. Diamond
- Harvard Medical School, Boston Children’s Hospital, Department of Urology, Boston, MA
| | - Allyson J. Fried
- John R. Oishei Children’s Hospital, Pediatric Urology of Western New York, Buffalo, NY
| | | | | | - Sabrina Z. Meyer
- John R. Oishei Children’s Hospital, Pediatric Urology of Western New York, Buffalo, NY
| | - Theresa Meyer
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL
| | - Cindy Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO
| | - Blake W. Palmer
- Cook Children’s Medical Center, Department of Pediatric Urology, Fort Worth, TX
| | - Alethea Paradis
- St. Louis Children’s Hospital, Division of Urologic Surgery, St. Louis, MO
| | - Kristy J. Reyes
- Cook Children’s Medical Center, Department of Pediatric Urology, Fort Worth, TX
| | - Amy Tishelman
- Harvard Medical School, Boston Children’s Hospital, Department of Urology, Boston, MA
- Boston College, Boston Children’s Hospital, Department of Psychiatry, Boston, MA
| | - Pierre Williot
- John R. Oishei Children’s Hospital, Pediatric Urology of Western New York, Buffalo, NY
| | | | - Elizabeth B. Yerkes
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL
| | - Larry L. Mullins
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
| | - Amy B. Wisniewski
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University, Stillwater, OK
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12
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Identifying the Resource Needs of Young People with Differences of Sex Development. J Clin Med 2022; 11:jcm11154372. [PMID: 35955990 PMCID: PMC9369005 DOI: 10.3390/jcm11154372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022] Open
Abstract
Adolescents with differences of sex development (DSD) often have complex medical, surgical, and psychological care needs and require age-appropriate resources. This cross-sectional study describes the past and current experiences of adolescents and young adults with DSD and their need for information and support. Participants aged 14−30 years with DSD diagnoses were identified, either from departmental records at the Royal Children’s Hospital (RCH), Melbourne, Australia, or from the private practice of a gynecologist linked to RCH. Anonymized data were collected from a specifically designed online survey. Of the 314 successfully traced patients, 91 (28.9%) completed the survey. Amongst respondents, older age was strongly correlated with higher levels of distress at the time of disclosure (b = 0.67, p < 0.001). People who reported greater understanding of their condition (b = −0.45, p = 0.010) and higher levels of support (b = −0.40, p = 0.003) identified lower levels of current distress. Respondents preferred to receive information from a specialist doctor, GP, or websites and reported information needs being highest during adolescence. Only one in four respondents recalled ever being offered psychological support. A number of perceived barriers to accessing support were identified. Our findings indicate that young people’s information and support needs may be best met by improving online resources, as well as increasing introductions to knowledgeable and appropriate primary care physicians, psychological services, and peer support groups. Further work to promote and increase engagement with psychological and peer support for those with DSD will be important.
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13
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Whitehead J, Hirsch J, Rosoklija I, Weisman AG, Dungan J, Finlayson C, Chen D, Johnson EK. Prenatal Detection and Evaluation of Differences of Sex Development: A Qualitative Interview Study of Parental Perspectives and Unmet Needs. Prenat Diagn 2022; 42:1332-1342. [PMID: 35670269 PMCID: PMC9545652 DOI: 10.1002/pd.6191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/11/2022]
Abstract
Objectives Prenatal diagnoses of differences of sex development (DSD) are increasing due to availability of cell‐free DNA screening (cell‐free DNA screening (cfDNA)). This study explores first‐hand experiences of parents whose children had prenatal findings of DSD. Methods Eligible parents were identified through chart review at a pediatric center and interviewed about their prenatal evaluation, decision making, informational sources, and support systems. Interviews were coded using a combined inductive and deductive thematic analysis. Parents also completed quantitative measures of decisional regret. Results Seventeen parents (13 mothers; 4 fathers) of 13 children (with 7 DSD diagnoses) were recruited. Four children had discordance between sex predicted by cfDNA versus prenatal ultrasound, and 2 had non‐binary appearing (atypical) genitalia on prenatal ultrasound. Of these 6, 3 were not offered additional prenatal testing or counseling. Most parents described tension between obtaining support through disclosure of their child's diagnosis and preserving their child's autonomy/privacy, highlighting the need for mental health support. Conclusion This is the first study to gather qualitative data from parents whose children had prenatal findings of DSD. We identified multiple targets for intervention to improve care for patients with DSD across the lifespan, including improvements in clinician education, pre‐ and post‐test counseling, and patient education materials.
What's already known about this topic? What does this study add?
Prenatal detection of potential differences of sex development (DSD) is increasing as the availability of non‐invasive prenatal screening increases. Algorithms have been developed for the diagnostic evaluation, but little is known about the psychosocial implications of that process. This study focuses on the first‐hand experiences of families whose children had prenatal findings of a potential DSD, to identify existing sources of support and information, and areas for future improvement.
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Affiliation(s)
- J Whitehead
- Division of Endocrinology, Chicago, United States.,Department of Pediatrics, Chicago, United States
| | | | | | | | | | - Courtney Finlayson
- Division of Endocrinology, Chicago, United States.,Department of Pediatrics, Chicago, United States
| | - Diane Chen
- Adolescent & Young Adult Medicine, Chicago, United States.,Department of Psychiatry & Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Chicago, United States.,Psychiatry & Behavioral Sciences, Chicago, United States
| | - Emilie K Johnson
- Urology, Chicago, United States.,Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Meyer-Bahlburg HFL. The Timing of Genital Surgery in Somatic Intersexuality: Surveys of Patients' Preferences. Horm Res Paediatr 2022; 95:12-20. [PMID: 35045418 DOI: 10.1159/000521958] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 01/10/2022] [Indexed: 11/19/2022] Open
Abstract
In recent years, intersex advocates, medical ethicists, and lawmakers have increasingly demanded a delay of genital surgery that is not acutely medically necessary in patients with somatic intersexuality to the age of consent. This study provides a review of published surveys of affected patients' own opinions on this issue. In part with search of PubMed 2000-2021, 10 pertinent surveys of patients were identified: 3 from the USA; 4 from European countries; and one each from Brazil, China, and Malaysia. All were based on samples of clinic patients, most of whom had previously undergone genital surgery. The majority of both XX and XY patients with somatic intersexuality favored early surgery, with somewhat more syndrome-specific variability in XY patients. The available survey data clearly indicate that a mandatory delay of genital surgery in all patients with somatic intersexuality to the age of consent would disregard the wishes of the majority of surveyed patients. A syndrome- and syndrome severity-specific individualized approach to surgery decisions appears more appropriate.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, and Department of Psychiatry, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York, USA
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15
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Sandberg DE, Gardner M. Differences/Disorders of Sex Development: Medical Conditions at the Intersection of Sex and Gender. Annu Rev Clin Psychol 2022; 18:201-231. [PMID: 35216524 PMCID: PMC10170864 DOI: 10.1146/annurev-clinpsy-081219-101412] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Defined as congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical, differences or disorders of sex development (DSDs) comprise many discrete diagnoses ranging from those associated with few phenotypic differences between affected and unaffected individuals to those where questions arise regarding gender of rearing, gonadal tumor risk, genital surgery, and fertility. Controversies exist in numerous areas including how DSDs are conceptualized, how to refer to the set of conditions and those affected by them, and aspects of clinical management that extend from social media to legislative bodies, courts of law, medicine, clinical practice, and scholarly research in psychology and sociology. In addition to these aspects, this review covers biological and social influences on psychosocial development and adjustment, the psychosocial and psychosexual adaptation of people born with DSDs, and roles for clinical psychologists in the clinical management of DSDs. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
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16
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Suorsa-Johnson KI, Gardner MD, Baskin A, Gruppen LD, Rose A, Rutter MM, Schafer-Kalkhoff T, Stacey D, van Leeuwen KD, Weidler EM, Sandberg DE. Defining successful outcomes and preferences for clinical management in differences/disorders of sex development: Protocol overview and a qualitative phenomenological study of stakeholders' perspectives. J Pediatr Urol 2022; 18:36.e1-36.e17. [PMID: 34876378 PMCID: PMC8983568 DOI: 10.1016/j.jpurol.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/25/2021] [Accepted: 10/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Utilizing a qualitative phenomenological design, the Defining Successful Outcomes and Trade-offs study examined stakeholder perspectives regarding optimal healthcare delivery and outcomes for individuals with a difference/disorder of sex development (DSD). OBJECTIVE We describe study methods and provide an overview of themes and subthemes. STUDY DESIGN Interviews were conducted with individuals with a DSD (n = 24), parents of those with a DSD (n = 19), healthcare providers (n = 37), and others (n = 30). Primary questions regarding clinical management of patients with DSD were: "What is a successful outcome?" and "How do you achieve it?" RESULTS Themes included: understanding of DSD diagnosis and self-efficacy in management is necessary but complex; patient and family psychological well-being; support from others versus being stigmatized; affected person experiences physical health and accepts the implications of their condition; complexities in DSD decision making, roles and expectations; and knowledgeable providers and multidisciplinary teams are essential, notwithstanding persisting barriers. Participants recognized competing values potentially forcing trade-offs in decision making. DISCUSSION Recognition of diverse and sometimes conflicting perspectives regarding optimal pathways of care and outcomes - both within and among those with DSD and their providers -promises to enhance shared decision making. CONCLUSION Diverse perspectives and perceptions of trade-offs associated with DSD healthcare emphasize the need to tailor care for patients and families.
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Affiliation(s)
- Kristina I Suorsa-Johnson
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Melissa D Gardner
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Alison Baskin
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA
| | - Larry D Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - Angela Rose
- Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Meilan M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA; Accord Alliance, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Dawn Stacey
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; School of Nursing, University of Ottawa, Ottawa, Canada
| | - Kathleen D van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - David E Sandberg
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA; Accord Alliance, USA.
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17
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Charron M, Saulnier K, Palmour N, Gallois H, Joly Y. Intersex Stigma and Discrimination: Effects on Patient-Centred Care and Medical Communication. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1089782ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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19
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Traino KA, Baudino MN, Kraft JD, Basile NL, Dattilo TM, Davis MP, Buchanan C, Cheng EY, Poppas DP, Wisniewski AB, Mullins LL. Factor Analysis of the Stigma Scale-Parent Version in Pediatric Disorders/Differences of Sex Development. STIGMA AND HEALTH 2021; 6:390-396. [PMID: 35497259 PMCID: PMC9053364 DOI: 10.1037/sah0000346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Stigma is a salient experience for both caregivers/parents and individuals with Disorders/Differences of Sex Development (DSD) as evidenced through qualitative and preliminary quantitative reports. However, few validated measures of associative stigma (i.e., vicarious stigma experienced through close association with someone who is socially stigmatized) for parents of children with DSD exist. The present study aims to (1) determine the factor structure of the adapted Stigma Scale - Parent, and (2) examine convergent validity of the factor structure with measures of parent psychosocial adjustment. Confirmatory factor analytic results revealed two factors: a parent-focused factor and a child-focused factor. The parent-focused factor demonstrated convergent validity with parent adjustment measures, but the child-focused factor did not. Together, these results indicate that parent-focused and child-focused stigma are distinct factors, with parent-focused associative stigma being related to parent adjustment following DSD diagnosis. Future research should further refine this measure to determine predictive validity and clinical value.
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Affiliation(s)
| | | | - Jacob D. Kraft
- Psychology Department, Oklahoma State University, Stillwater, OK
| | - Nathan L. Basile
- Psychology Department, Oklahoma State University, Stillwater, OK
| | | | - Morgan P. Davis
- Psychology Department, Oklahoma State University, Stillwater, OK
| | - Cindy Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO
| | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL
| | - Dix P. Poppas
- Phyllis & David Komansky Center for Children’s Health of New York Presbyterian Hospital Weill Cornell Medical Center
| | | | - Larry L. Mullins
- Psychology Department, Oklahoma State University, Stillwater, OK
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20
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Perez MN, Clawson AH, Baudino MN, Austin PF, Baskin LS, Chan YM, Cheng EY, Coplen D, Diamond DA, Fried AJ, Kolon T, Kropp B, Lakshmanan Y, Meyer T, Nokoff NJ, Palmer BW, Paradis A, Poppas DP, Reyes KJS, Williot P, Wolfe-Christensen C, Yerkes EB, Wisniewski AB, Mullins LL. Distress Trajectories for Parents of Children With DSD: A Growth Mixture Model. J Pediatr Psychol 2021; 46:588-598. [PMID: 33594414 DOI: 10.1093/jpepsy/jsab004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/06/2020] [Accepted: 01/09/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This study identifies trajectories of parent depressive symptoms after having a child born with genital atypia due to a disorder/difference of sex development (DSD) or congenital adrenal hyperplasia (CAH) and across the first year postgenitoplasty (for parents who opted for surgery) or postbaseline (for parents who elected against surgery for their child). Hypotheses for four trajectory classes were guided by parent distress patterns previously identified among other medical conditions. METHODS Participants included 70 mothers and 50 fathers of 71 children diagnosed with a DSD or CAH with reported moderate to high genital atypia. Parents were recruited from 11 US DSD specialty clinics within 2 years of the child's birth and prior to genitoplasty. A growth mixture model (GMM) was conducted to identify classes of parent depressive symptoms over time. RESULTS The best fitting model was a five-class linear GMM with freely estimated intercept variance. The classes identified were termed "Resilient," "Recovery," "Chronic," "Escalating," and "Elevated Partial Recovery." Four classes have previously been identified for other pediatric illnesses; however, a fifth class was also identified. The majority of parents were classified in the "Resilient" class (67.6%). CONCLUSIONS This study provides new knowledge about the trajectories of depressive symptoms for parents of children with DSD. Future studies are needed to identify developmental, medical, or familial predictors of these trajectories.
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Affiliation(s)
- Megan N Perez
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University
| | - Ashley H Clawson
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University
| | - Marissa N Baudino
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University
| | | | - Laurence S Baskin
- Department of Urology, University of California San Francisco Medical Center
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Harvard Medical School and Boston Children's Hospital
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | | | - David A Diamond
- Department of Urology, Boston Children's Hospital, Harvard Medical School
| | - Allyson J Fried
- Pediatric Urology of Western New York, John R. Oishei Children's Hospital
| | - Thomas Kolon
- Division of Urology, Children's Hospital of Philadelphia
| | - Bradley Kropp
- Department of Pediatric Urology, Cook Children's Medical Center
| | | | - Theresa Meyer
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Natalie J Nokoff
- Department of Endocrinology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus
| | - Blake W Palmer
- Department of Pediatric Urology, Cook Children's Medical Center
| | | | - Dix P Poppas
- Department of Urology, New York Presbyterian Weill Cornell Medicine
| | | | - Pierre Williot
- Pediatric Urology of Western New York, John R. Oishei Children's Hospital
| | | | - Elizabeth B Yerkes
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Amy B Wisniewski
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University
| | - Larry L Mullins
- Center for Pediatric Psychology, Psychology Department, Oklahoma State University
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21
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Examining quality of life in an Australian cohort of people with epilepsy over six years - Understanding the role of stigma and mood. Epilepsy Behav 2020; 113:107473. [PMID: 33142200 DOI: 10.1016/j.yebeh.2020.107473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 01/23/2023]
Abstract
AIM Research examining quality of life (QoL) among people living with epilepsy (PWE) consistently highlights the detrimental impact of stigma, anxiety, and depression, as well as the dynamic and changing nature of QoL over time. This paper represents the first panel study of the Australian Epilepsy Longitudinal Survey (AELS), examining factors that influence the QoL of PWE over a six-year interval, particularly focusing on experiences of stigma, depression, and anxiety. METHODS Ninety-two adults participated in both Wave 2 (T1; 2010) and Wave 4 (T2; 2016/17) of the AELS. Average age at T2 was 53.4 years [standard deviation (SD) = 15.3; range: 22-82; 55% female]. Over the study interval, there was a shift towards more younger participants moving out of high school and older participants moving into retirement. We explored the impact of (i) experiences of stigma, (ii) mood, and (iii) sociodemographic factors on QoL at both T1 and T2 via the use of correlation analyses. Hierarchical regression was used to determine the strongest predictors of QoL at T2. RESULTS Occurrence of recent seizures, stigma, anxiety, and depression measured at T1 were all significantly correlated with total QoL at both T1 and T2. Sociodemographic factors including years of education, and weekly income before tax were not significantly correlated with QoL at either T1 or T2. QoL and depression at T1 were identified as the strongest predictors of QoL at T2 (six years later). DISCUSSION The current study supports previous research highlighting the importance of psychological factors in understating QoL in PWE, particularly stigma, anxiety, and depression. In particular, it highlights the impact of depression on QoL over a 6-year interval, providing evident for the long-term nature of this relationship.
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22
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Ali SR, Macqueen Z, Gardner M, Xin Y, Kyriakou A, Mason A, Shaikh MG, Wong SC, Sandberg DE, Ahmed SF. Parent-reported outcomes in young children with disorders/differences of sex development. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2020; 2020:3. [PMID: 32082389 PMCID: PMC7020572 DOI: 10.1186/s13633-020-0073-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/27/2020] [Indexed: 11/24/2022]
Abstract
Background There is a paucity of tools that can be used in routine clinical practice to assess the psychosocial impact of Disorders/Differences of Sex Development (DSD) on parents and children. Objective To evaluate the use of short Parent Self-Report and Parent Proxy-Report questionnaires that can be used in the outpatient setting. Methods Previously validated DSD-specific and generic items were combined to develop a Parent Self-Report questionnaire and a Parent Proxy-Report questionnaire for children under 7 years. Of 111 children approached at one tertiary paediatric hospital, the parents of 95 children (86%) with DSD or other Endocrine conditions completed these questionnaires. Results Questionnaires took under 10 min to complete and were found to be easy to understand. Compared to reference, fathers of children with DSD reported less stress associated with Clinic Visits (p = 0.02) and managing their child’s Medication (p = 0.04). However, parents of children with either DSD or other Endocrine conditions reported more symptoms of Depression (p = 0.03). Mothers of children with DSD reported greater Future Concerns in relation to their child’s condition (median SDS − 0.28; range − 2.14, 1.73) than mothers of children with other Endocrine conditions (SDS 1.17; − 2.00, 1.73) (p = 0.02). Similarly, fathers of children with DSD expressed greater Future Concerns (median SDS -1.60; − 4.21, 1.00) than fathers of children with other Endocrine conditions (SDS 0.48; − 2.13, 1.52) (p = 0.04). Conclusion DSD was associated with greater parental concerns over the child’s future than other Endocrine conditions. Brief parent-report tools in DSD can be routinely used in the outpatient setting to assess and monitor parent and patient needs.
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Affiliation(s)
- Salma R Ali
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Zoe Macqueen
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Melissa Gardner
- 2Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan USA
| | - Yiqiao Xin
- 3Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andreas Kyriakou
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Avril Mason
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - M Guftar Shaikh
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Sze C Wong
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - David E Sandberg
- 2Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan USA
| | - S Faisal Ahmed
- 1Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Wang D, Jia Y, Gao W, Chen S, Li M, Hu Y, Luo F, Chen X, Xu H. Relationships between Stigma, Social Support, and Distress in Caregivers of Chinese Children with Imperforate Anus: A Multicenter Cross-Sectional Study. J Pediatr Nurs 2019; 49:e15-e20. [PMID: 31378408 DOI: 10.1016/j.pedn.2019.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This study was conducted to explore the relationships between stigma, social support, and distress in caregivers of children with imperforate anus (IA) and determine whether social support mediates the relationship between stigma and distress. DESIGN AND METHODS This cross-sectional study was conducted in three tertiary children's hospitals in Eastern China. Primary caregivers completed the Social Support Scale and the Chinese versions of the Parent Stigma Scale and Kessler Psychological Distress Scale, and provided their demographic information. The children's demographic and clinical data were also collected. The hypothesized relations were explored using structural equation modeling via the bootstrap method. RESULTS A total of 229 caregivers were enrolled. Distress was positively associated with stigma (r = 0.396, P < 0.01) and negatively associated with social support (r = -0.413, P < 0.01) in all dimensions (r = 0.314-0.346, P < 0.01). Stigma was also negatively correlated with social support (r = 0.280, P < 0.01). Furthermore, social support could partially mediate the relationship between stigma and distress (b = 0.135; 95% confidence interval: 0.072, 0.233). CONCLUSIONS Stigma can increase caregivers' distress, while social support can reduce it. Stigma can also negatively influence caregivers' social support. Therefore, stigma should be mitigated to enhance caregivers' social support and decrease their distress. PRACTICE IMPLICATIONS The study findings may aid in the identification of the psychological status of caregivers of children with IA, and also inform targeted intervention programs.
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Affiliation(s)
- Dan Wang
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Yushuang Jia
- Nursing Department, the 2nd Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Wei Gao
- Department of Pediatric Surgery, Anhui Provincial Children's Hospital, Anhui, China
| | - Shuohui Chen
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Mengting Li
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Yan Hu
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Feixiang Luo
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Xiaofei Chen
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Hongzhen Xu
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China.
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Perez MN, Delozier AM, Aston CE, Austin P, Baskin L, Chan YM, Cheng EY, Diamond DA, Fried A, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Nokoff N, Palmer B, Paradis A, Poppas D, Scott Reyes KJ, Swartz JM, Tishelman A, Wisniewski AB, Wolfe-Christensen C, Yerkes E, Mullins LL. Predictors of Psychosocial Distress in Parents of Young Children with Disorders of Sex Development. J Urol 2019; 202:1046-1051. [PMID: 31268850 DOI: 10.1097/ju.0000000000000424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated demographic, financial and support predictors of distress for parents of young children with disorders of sex development including atypical genital development, and characterized early parental experiences. This work extends our previous findings to identify those parents at risk for distress. MATERIALS AND METHODS Participants included mothers (76) and fathers (63) of a child (78) diagnosed with disorders of sex development characterized by moderate to severe genital atypia. Parents completed a demographic questionnaire, measures of anxious and depressive symptoms, quality of life, illness uncertainty and posttraumatic stress symptoms, and rated their satisfaction with the appearance of their child's genitalia. RESULTS Depressive and posttraumatic stress symptoms of caregivers were comparable to standardized norms while levels of anxious symptoms were below norms. A subset of parents reported clinically elevated symptoms. Overall 26% of parents reported anxious symptoms, 24% reported depressive symptoms and 17% reported posttraumatic stress symptoms. Levels of illness uncertainty were lower than those of parents of children with other chronic illnesses. Differences by parent sex emerged, with mothers reporting greater distress. Lower income, increased medical care and travel expenses, and having no other children were related to increased psychosocial distress. CONCLUSIONS Early psychosocial screening is recommended for parents of children with disorders of sex development. Clinicians should be aware that financial burden and lack of previous parenting experience are risk factors for distress.
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Affiliation(s)
| | | | | | - Paul Austin
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Laurence Baskin
- University of California San Francisco Medical Center, San Francisco, California
| | | | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Allyson Fried
- John R. Oishei Children's Hospital, Buffalo, New York
| | | | - Thomas Kolon
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Sabrina Meyer
- John R. Oishei Children's Hospital, Buffalo, New York
| | - Theresa Meyer
- Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Blake Palmer
- Cook Children's Medical Center, Ft. Worth, Texas
| | | | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
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Abstract
Differences of sex development (DSD) include a variety of complex congenital genitourinary abnormalities-whether sporadic or hereditary. The 2006 DSD Consensus Statement and 2016 Update Consensus Statement encourage better communication among providers, between providers and parents, as well as among providers, parents, and patients when developmentally appropriate.1,2 However, a lack of clear communication about the diagnosis and its sequelae may occur at three levels: (1) disclosure from DSD patients' families to their physician, (2) disclosure from patients to their families/communities, and (3) disclosure from the physician to the DSD patient. Additionally, there is a paucity of research available on how culture can impact disclosure among individuals with DSDs. This article discusses disclosure among the various stakeholders and briefly explores the impact of cultural expectations and beliefs with regards to disclosure.
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Affiliation(s)
- Erica M Weidler
- Reproductive Anomalies/Differences of Sex Development Clinic, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States.
| | - Karen E Peterson
- Reproductive Anomalies/Differences of Sex Development Clinic, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States
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Psychological perspectives to early surgery in the management of disorders/differences of sex development. Curr Opin Pediatr 2019; 31:570-574. [PMID: 31246626 DOI: 10.1097/mop.0000000000000784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The review focuses on genitoplasty, performed on young children with disorders/differences of sex development (DSD) to 'typify' ambiguous external genitalia and intended to result in either male or female-appearing genitals. Consensus on whether or not early genitoplasty is optimal or appropriate has yet to be achieved. This article reviews arguments in favor of early surgery as well as those disputing their justification. RECENT FINDINGS Arguments supporting early genitoplasty include the assumption that a child's genital anatomy should match their gender of rearing for optimal psychosocial development and that outcomes are better physically and psychologically than when surgery is deferred. Those disputing their justification argue that they deny patients the right to participate in irreversible decisions related to anatomy and gender, revoke the possibility of an open future, and violate basic human rights. Clinical management includes recommendations for interdisciplinary care integrating psychologists, and shared decision-making processes to assist families in carefully considering options. SUMMARY Early genital surgery in DSD care is controversial with compelling arguments put forth by both proponents and opponents. Relevant issues can be examined from ethical, psychological, cultural and medical perspectives - all of which need to be accounted for in both research and standard of care development.
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Liao LM, Hegarty P, Creighton S, Lundberg T, Roen K. Clitoral surgery on minors: an interview study with clinical experts of differences of sex development. BMJ Open 2019; 9:e025821. [PMID: 31171549 PMCID: PMC6561419 DOI: 10.1136/bmjopen-2018-025821] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Lih-Mei Liao
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Hegarty
- School of Psychology, University of Surrey, Guildford, UK
| | - Sarah Creighton
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tove Lundberg
- Department of Psychology, Lund University, Lund, Sweden
| | - Katrina Roen
- School of Social Sciences, University of Waikato, Hamilton, New Zealand
- Department of Psychology, University of Oslo, Oslo, Norway
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Roen K. Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice. JOURNAL OF SEX RESEARCH 2019; 56:511-528. [PMID: 30907687 DOI: 10.1080/00224499.2019.1578331] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Katrina Roen
- a Department of Sociology , University of Waikato
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30
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Hegarty P, Smith A, Bogan‐Carey T. Stigma as framed onYouTube: Effects of personal experiences videos on students’ beliefs about medicalizing intersex. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 2019. [DOI: 10.1111/jasp.12570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Hegarty
- School of Psychology University of Surrey Guildford UK
| | - Annette Smith
- School of Psychology University of Surrey Guildford UK
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Timmermans S, Yang A, Gardner M, Keegan CE, Yashar BM, Fechner PY, Shnorhavorian M, Vilain E, Siminoff LA, Sandberg DE. Does Patient-centered Care Change Genital Surgery Decisions? The Strategic Use of Clinical Uncertainty in Disorders of Sex Development Clinics. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2018; 59:520-535. [PMID: 30303019 DOI: 10.1177/0022146518802460] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
| | - Ashelee Yang
- 1 University of California-Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | - Eric Vilain
- 4 Children's National Health System, Washington, DC, USA
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Kung KTF, Spencer D, Pasterski V, Neufeld SAS, Hindmarsh PC, Hughes IA, Acerini CL, Hines M. Emotional and behavioral adjustment in 4 to 11-year-old boys and girls with classic congenital adrenal hyperplasia and unaffected siblings. Psychoneuroendocrinology 2018; 97:104-110. [PMID: 30015005 DOI: 10.1016/j.psyneuen.2018.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/20/2018] [Accepted: 07/02/2018] [Indexed: 01/27/2023]
Abstract
It has been suggested that atypical hormone environments during early development may contribute to subsequent development of psychopathology. Also, it has been suggested that individuals with the autosomal recessive genetic variant, classic congenital adrenal hyperplasia (CAH), might be at increased risk of psychopathology. The present study examined emotional and behavioral adjustment in young children with CAH and their unaffected siblings in the United Kingdom. The parent-reported version of the Strengths and Difficulties Questionnaire (SDQ) was employed to assess adjustment in children aged 4 to 11 years. There were 38 boys with CAH, 43 girls with CAH, 23 unaffected brothers, and 31 unaffected sisters. No differences in emotional or behavioral problems were found between boys or girls with CAH and unaffected same-sex siblings. In addition, affected and unaffected boys in the current sample generally did not differ from boys in the general population. However, compared with girls in the general population, girls with CAH had more difficulties related to conduct problems, hyperactivity/ inattention, and prosocial behavior, and unaffected sisters had more difficulties related to peer problems, conduct problems, and prosocial behavior. These findings suggest that both girls with CAH and unaffected sisters of girls or boys with CAH may be at increased risk of developing behavioral problems. Potential influences related to the early hormone environment, familial process, and social stigma are considered.
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Affiliation(s)
- Karson T F Kung
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, UK.
| | - Debra Spencer
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, UK
| | - Vickie Pasterski
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, UK; Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Sharon A S Neufeld
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, UK
| | - Peter C Hindmarsh
- Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Melissa Hines
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, UK
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Tiryaki S, Tekin A, Yağmur İ, Özen S, Özbaran B, Gökşen D, Darcan Ş, Ulman İ, Avanoğlu A. Parental Perception of Terminology of Disorders of Sex Development in Western Turkey. J Clin Res Pediatr Endocrinol 2018; 10:216-222. [PMID: 29595517 PMCID: PMC6083470 DOI: 10.4274/jcrpe.0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Disorders of sex development (DSD) is a nomenclature intended to defeat the discomfort of families and patients and has found worldwide usage. The aim of this study was to address the perception and usage of terminology among the parents of DSD patients in a tertiary center in western Turkey. METHODS The records of the DSD council (multidisciplinary team where each patient with DSD is discussed) between years 2008-2015 were reviewed retrospectively. Data including details of the management process, patient characteristics and follow-up details were noted. Then inquiries reflecting parental perception about terminology were implemented during clinical visits. RESULTS In total, 121 patients were evaluated in monthly meetings of the DSD council and 79 inquiries were completed. Fifty-one percent of the families admitted knowing the terms DSD, ambiguous genitalia, “dubious genitals” and intersex. However, only 2% preferred using DSD, 6% intersex and 14% ambiguous genitalia. Fifty-two percent of the parents used a disease name in Latin (mostly hypospadias) addressing the disorder. The offspring of 69% of the parents who were familiar with the name “dubious genitals” were diagnosed in the neonatal period. The preferred terminology used by parents was strongly associated with the terminology used most commonly in the medical speciality their child most often attended. CONCLUSION Each country has its own social norms. We suggest therefore that local committees including medical professionals, patients and families should be employed to develop proper terminology.
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Affiliation(s)
- Sibel Tiryaki
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey Phone: +90 533 231 11 91 E-mail:
| | - Ali Tekin
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - İsmail Yağmur
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Burcu Özbaran
- Ege University Faculty of Medicine, Department of Child and Adolescent Psychiatry, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - İbrahim Ulman
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
| | - Ali Avanoğlu
- Ege University Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, Turkey
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Meyer-Bahlburg HFL, Khuri J, Reyes-Portillo J, Ehrhardt AA, New MI. Stigma Associated with Classical Congenital Adrenal Hyperplasia in Women's Sexual Lives. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:943-951. [PMID: 28523454 DOI: 10.1007/s10508-017-1003-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 05/28/2023]
Abstract
The risk of intersex-related stigma often serves as social indication for "corrective" genital surgery, but has not been comprehensively documented. In preparation for the development of an intersex-specific stigma assessment tool, this qualitative project aimed to explore stigma in girls and women with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. As part of a comprehensive follow-up project, 62 adult women with classical CAH (age range 18-51 years) took part in an open-ended retrospective interview focusing on the impact of CAH and its treatment on various aspects of girls' and women's lives. Deductive qualitative content analysis (Patton, 2014) of de-identified transcripts involved categorization of three types of stigma: experienced, anticipated, and internalized. Two-fifths of the participants reported CAH-related stigma in romantic/sexual situations. Stigma enactment by romantic partners occurred in reaction to both genital and non-genital sex-atypical features of CAH and sometimes included explicit questioning of the women's true gender. Stigma anticipation by the women and their related avoidance of nudity, genital exposure, and romantic involvement altogether were frequent. Internalization of stigma occurred as well. In conclusion, the data suggest that many women with CAH experience, anticipate, and/or internalize intersex-related stigma in the context of their romantic/sexual lives.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
| | - Jananne Khuri
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Jazmin Reyes-Portillo
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Anke A Ehrhardt
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Maria I New
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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35
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Psychosocial implications of disorders of sex development treatment for parents. Curr Opin Urol 2018; 27:11-13. [PMID: 27584026 DOI: 10.1097/mou.0000000000000344] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Historically, studies of caregivers of children with disorders of sex development (DSD) have been limited. RECENT FINDINGS Recent data reveal that parents of young children with DSD report increased stress, anxiety, depression, and decreased quality of life in ways that are similar to parents of children with other types of chronic illnesses. Also similar to other chronic illnesses of childhood, parents of children with DSD exhibit overprotective parenting and perceive their child as being vulnerable. These emotions and behaviors exhibited by parents are concerning as they may limit an affected child's emotional and social development over time. Perhaps, more unique to the situation of DSD is the perceived, or real, child-focused stigma experienced by parents of children with DSD. SUMMARY Interventions to improve parents' psychosocial adaptation to their child's medical condition, including coaching in how to discuss their child's condition in a manner that makes them feel safe and supported, are needed to optimize outcomes for families.
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36
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Ernst MM, Gardner M, Mara CA, Délot EC, Fechner PY, Fox M, Rutter MM, Speiser PW, Vilain E, Weidler EM, Sandberg DE. Psychosocial Screening in Disorders/Differences of Sex Development: Psychometric Evaluation of the Psychosocial Assessment Tool. Horm Res Paediatr 2018; 90:368-380. [PMID: 30783028 PMCID: PMC6512800 DOI: 10.1159/000496114] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 12/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/AIMS Utilization of a psychosocial screener to identify families affected by a disorder/difference of sex development (DSD) and at risk for adjustment challenges may facilitate efficient use of team resources to optimize care. The Psychosocial Assessment Tool (PAT) has been used in other pediatric conditions. The current study explored the reliability and validity of the PAT (modified for use within the DSD population; PAT-DSD). METHODS Participants were 197 families enrolled in the DSD-Translational Research Network (DSD-TRN) who completed a PAT-DSD during a DSD clinic visit. Psychosocial data were extracted from the DSD-TRN clinical registry. Internal reliability of the PAT-DSD was tested using the Kuder-Richardson-20 coefficient. Validity was examined by exploring the correlation of the PAT-DSD with other measures of caregiver distress and child emotional-behavioral functioning. RESULTS One-third of families demonstrated psychosocial risk (27.9% "Targeted" and 6.1% "Clinical" level of risk). Internal reliability of the PAT-DSD Total score was high (α = 0.86); 4 of 8 subscales met acceptable internal reliability. A priori predicted relationships between the PAT-DSD and other psychosocial measures were supported. The PAT-DSD Total score related to measures of caregiver distress (r = 0.40, p < 0.001) and to both caregiver-reported and patient self-reported behavioral problems (r = 0.61, p < 0.00; r = 0.37, p < 0.05). CONCLUSIONS This study provides evidence for the reliability and validity of the PAT-DSD. Given variability in the internal reliability across subscales, this measure is best used to screen for overall family risk, rather than to assess specific psychosocial concerns.
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Affiliation(s)
- Michelle M. Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Constance A. Mara
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Patricia. Y. Fechner
- Department of Pediatrics, University of Washington, Seattle Children’s DSD Program, Seattle, Washington
| | - Michelle Fox
- Department of Pediatrics, UCLA School of Medicine, Los Angeles, California
| | - Meilan. M. Rutter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Phyllis W. Speiser
- Department of Pediatrics, Cohen Children’s Medical Center of New York and Zucker School of Medicine at Hofstra University, New Hyde Park, New York
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Erica M. Weidler
- Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona; Accord Alliance, Whitehouse Station, New Jersey
| | | | - David E. Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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Meyer-Bahlburg HFL, Khuri J, Reyes-Portillo J, New MI. Stigma in Medical Settings As Reported Retrospectively by Women With Congenital Adrenal Hyperplasia (CAH) for Their Childhood and Adolescence. J Pediatr Psychol 2017; 42:496-503. [PMID: 27189692 DOI: 10.1093/jpepsy/jsw034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 03/29/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives To perform a qualitative study of stigma experienced in medical settings by children and adolescents with congenital genital ambiguity (CGA). Methods 62 women with classical congenital adrenal hyperplasia (CAH) of variable severity took part in a qualitative retrospective interview that focused on the impact of CAH and its medical treatment, with an emphasis on childhood and adolescence. Categorization of stigmatization was based on deductive content analysis of the interview transcripts. Results Many women recalled experiencing the genital examinations in childhood and adolescence as adverse, stigmatizing events, leading to avoidance reactions and self-perception as abnormal, particularly when the examinations included groups of trainees. Some women also experienced as adverse the nonverbal and verbal reactions of individual physicians who were unfamiliar with CGA. Conclusions Genital examinations constitute salient events for children and adolescents with CGA. They are easily experienced as strongly stigmatizing, especially when combined with teaching.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute, Riverside Drive, Unit 15, New York, NY, USA.,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, Riverside Drive, Unit 15, New York, NY, USA
| | - Jananne Khuri
- NYS Psychiatric Institute, Riverside Drive, Unit 15, New York, NY, USA.,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, Riverside Drive, Unit 15, New York, NY, USA
| | - Jazmin Reyes-Portillo
- NYS Psychiatric Institute, Riverside Drive, Unit 15, New York, NY, USA.,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, Riverside Drive, Unit 15, New York, NY, USA
| | - Maria I New
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Schweizer K, Brunner F, Gedrose B, Handford C, Richter-Appelt H. Coping With Diverse Sex Development: Treatment Experiences and Psychosocial Support During Childhood and Adolescence and Adult Well-Being. J Pediatr Psychol 2017; 42:504-519. [PMID: 27452605 DOI: 10.1093/jpepsy/jsw058] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 05/30/2016] [Indexed: 12/23/2022] Open
Abstract
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.
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Alpern AN, Gardner M, Kogan B, Sandberg DE, Quittner AL. Development of Health-Related Quality of Life Instruments for Young Children With Disorders of Sex Development (DSD) and Their Parents. J Pediatr Psychol 2017; 42:544-558. [PMID: 27026663 DOI: 10.1093/jpepsy/jsw022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/01/2016] [Indexed: 11/13/2022] Open
Abstract
Objective Research in disorders of sex development (DSD) is hindered by a lack of standardized measures sensitive to the experiences of affected children and families. We developed and evaluated parent proxy (children 2-6 years) and parent self-report (children ≤6 years) health-related quality of life (HRQoL) instruments for DSD. Methods Items were derived from focus groups and open-ended interviews. Clarity and comprehensiveness were assessed with cognitive interviews. Psychometric properties were examined in a field survey of 94 families. Results Measures demonstrated adequate to good psychometrics, including internal consistency, test-retest reliability, convergent validity, and ability to detect known-group differences. Parents reported greatest stress on Early Experiences , Surgery , and Future Concerns scales. Conclusions These instruments identify patients' and families' needs, monitor health and quality of life status, and can evaluate clinical interventions. Findings highlight the need for improved psychosocial support during the diagnostic period, better parent-provider communication, and shared decision-making. HRQoL measures are needed for older youth.
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Affiliation(s)
- Adrianne N Alpern
- Department of Psychology, University of Miami, Ponce De Leon Blvd., Coral Gables, FL, USA
| | - Melissa Gardner
- Department of Pediatrics; Division of Pediatric Psychology and Child Health Evaluation & Research (CHEAR) Unit, University of Michigan, Ann Arbor, Michigan, USA
| | - Barry Kogan
- Division of Urology, Albany Medical College, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics; Division of Pediatric Psychology and Child Health Evaluation & Research (CHEAR) Unit, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexandra L Quittner
- Department of Psychology, University of Miami, Ponce De Leon Blvd., Coral Gables, FL, USA
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40
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Chivers C, Burns J, Deiros Collado M. Disorders of sex development: Mothers' experiences of support. Clin Child Psychol Psychiatry 2017; 22:675-690. [PMID: 28752770 DOI: 10.1177/1359104517719114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An increasing body of research has sought to determine the impact of Disorders of Sex Development (DSD) on the family of the affected child. Little is currently understood about the support needs of the family and how well these needs are met. METHODS Interpretive Phenomenological Analysis was used to analyse semi-structured interviews with eight mothers of children with DSD about their experiences of support. RESULTS Four master themes emerged which encapsulated (a) the stages in their child's development when mothers most needed support, (b) the importance of developing an understanding of the child's condition, (c) the lack of acknowledgement of the emotional needs of the parent and (d) the importance of having close and trusted networks for support. Continuity and availability of support were considered important and while all participants prioritised maintaining privacy about the condition, a minority felt that this impacted the level of support they received. CONCLUSIONS Key time points for support were identified and while some felt that they were well supported others felt that the support available did not meet their emotional needs. Clinical implications and directions for future research were considered.
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Affiliation(s)
- Clare Chivers
- 1 Greenwich Child and Adolescent Mental Health Services, Oxleas NHS Foundation Trust, UK.,2 Faculty of Social and Applied Sciences, Canterbury Christ Church University, UK
| | - Jan Burns
- 2 Faculty of Social and Applied Sciences, Canterbury Christ Church University, UK
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Dessens A, Guaragna-Filho G, Kyriakou A, Bryce J, Sanders C, Nordenskjöld A, Rozas M, Iotova V, Ediati A, Juul A, Krawczynski M, Hiort O, Faisal Ahmed S. Understanding the needs of professionals who provide psychosocial care for children and adults with disorders of sex development. BMJ Paediatr Open 2017; 1:e000132. [PMID: 29637150 PMCID: PMC5843008 DOI: 10.1136/bmjpo-2017-000132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Disorders in sex development (DSD) can be treated well medically, but families will encounter many psychosocial challenges. Promoting counselling to facilitate acceptance and coping is important yet equality of access is unknown. This study investigated the modalities of psychosocial care provided in centres of DSD care. METHODS An international survey conducted among 93 providers of psychosocial care, identified through clinical networks, registries and professional forums. RESULTS Forty-six respondents from 22 different countries filled out the survey (49%). Most respondents (78%) were based in hospital-based expert teams. Referrals came from paediatric endocrinologists (76%), gynaecologists (39%) and paediatric urologists (37%). Psychological counselling was most frequently given to parents (74%), followed by children (39%), adolescents (37%) and adults (11%) and was most frequently focused on coping and acceptance of DSD (54%), education (52%), the atypical body (39%) and genital (41%), decisions on genital surgery (33%), complications with sexual intercourse (29%), disclosure (28%) and acceptance of infertility (11%). Respondents most frequently observed DSD related confusion about gender (54%), acceptance of cross gender behaviour (50%), anxiety (43%) and sadness and depression (38%). CONCLUSIONS Most psychosocial care is provided to parents. It is assumed that parental support is important as acceptance is conditional to become affectionate caretakers. Although it may be more difficult for youngsters to communicate about their condition and treatment, providing opportunity to bring up issues that are important for them, is imperative. Clinicians and parents should be aware that parental and patients' interests may not correspond completely. Psychosocial management should also include transition and adult care.
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Affiliation(s)
- Arianne Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus Medical Center Rotterdam - Sophia, Rotterdam, The Netherlands
| | - Guilherme Guaragna-Filho
- Interdisciplinary Group of Study of Sex Determination and Differentiation (GIEDDS), School of Medicine (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Jillian Bryce
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Caroline Sanders
- University of Northern British Columbia, Canada & Adjunct Alder Hey Children Hospital, NHS Trust UK, Prince George, Canada
| | - Agneta Nordenskjöld
- Paediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Marta Rozas
- GrApSIA (Grupo de Apoyo al Síndrome de Insensibilidad a los Andrógenos), Barcelona, Spain
| | - Violeta Iotova
- Department of Paediatrics, Medical University of Varna, Varna, Bulgaria
| | - Annastasia Ediati
- Department of Clinical Psychology, Diponegoro University, Semarang, Indonesia
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maciej Krawczynski
- Department of Medical Genetics, Poznan University of Medical Science, Poznań, Poland
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
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Swartz JM, Ciarlo R, Denhoff E, Abrha A, Diamond DA, Hirschhorn JN, Chan YM. Variation in the clinical and genetic evaluation of undervirilized boys with bifid scrotum and hypospadias. J Pediatr Urol 2017; 13:293.e1-293.e6. [PMID: 28215832 PMCID: PMC5483185 DOI: 10.1016/j.jpurol.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/04/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Bifid scrotum and hypospadias can be signs of undervirilization, yet boys presenting with these findings often do not undergo genetic evaluation. In some cases, identifying an underlying genetic diagnosis can help to optimize clinical care and improve guidance given to patients and families. OBJECTIVES The aim of this study was to characterize current practice for genetic evaluation of patients with bifid scrotum, and to identify approaches with a good diagnostic yield. METHODS A retrospective study of the Boston Children's Hospital electronic medical records (1993-2015) was conducted using the search term "bifid scrotum" and clinical data were extracted. Data were abstracted into a REDCap database for analysis. Statistical analysis was performed using SPSS, SAS, and Excel software. RESULTS The search identified 110 subjects evaluated in the Urology and/or Endocrinology clinics for bifid scrotum. Genetic testing (including karyotype, microarray, or targeted testing) was performed on 64% of the subjects with bifid scrotum; of those tested, 23% (15% of the total cohort of 110 subjects) received a confirmed genetic diagnosis. Karyotype analysis, when performed, led to a diagnosis in 17% of patients. Of the ten instances when androgen receptor gene sequencing was performed, a pathogenic mutation was identified 20% of the time. CONCLUSION This study demonstrated that the majority of individuals with moderate undervirilization resulting in bifid scrotum do not receive a genetic diagnosis. Over a third of the analyzed subjects did not have any genetic testing, even though karyotype analysis and androgen receptor (AR) sequencing were both relatively high yield for identifying a genetic etiology. Increased utilization of traditional genetic approaches could significantly improve the ability to find a genetic diagnosis.
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Affiliation(s)
- J M Swartz
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA.
| | - R Ciarlo
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - E Denhoff
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - A Abrha
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - D A Diamond
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - J N Hirschhorn
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Program in Medical and Population Genetics, Cambridge, MA, USA
| | - Y-M Chan
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA
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43
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Sandberg DE, Pasterski V, Callens N. Introduction to the Special Section: Disorders of Sex Development. J Pediatr Psychol 2017; 42:487-495. [PMID: 28499017 PMCID: PMC5896587 DOI: 10.1093/jpepsy/jsx065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Nina Callens
- Department of Pediatrics, University of Michigan Medical School
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Wolfe-Christensen C, Wisniewski AB, Mullins AJ, Reyes KJ, Austin P, Baskin L, Bernabé K, Cheng E, Fried A, Frimberger D, Galan D, Gonzalez L, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Nokoff NJ, Palmer B, Poppas D, Paradis A, Yerkes E, Mullins LL. Changes in levels of parental distress after their child with atypical genitalia undergoes genitoplasty. J Pediatr Urol 2017; 13:32.e1-32.e6. [PMID: 28041823 PMCID: PMC5889974 DOI: 10.1016/j.jpurol.2016.10.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The birth of a child with a disorder of sex development (DSD) and atypical genitalia can be traumatizing and isolating for families. Parents of children with DSD are at risk for increased levels of psychological distress, including depression, anxiety, illness uncertainty (IU), post-traumatic stress symptoms (PTSS), and impairments in quality of life (QOL). Our previous report indicated that although the majority of parents of children with atypical genitalia were coping well prior to the child's genitoplasty, approximately 25% of them reported experiencing some type of psychological distress. OBJECTIVE The current study sought to examine the trajectory of parental psychological distress prior to, and 6 months after their child underwent genitoplasty. METHODS Parents were recruited as part of an ongoing, prospective, multi-site study involving 10 pediatric hospitals with specialized care for children with atypical genitalia. Results from 49 parents (27 mothers, 22 fathers) of 28 children (17 female sex of rearing, 11 male sex of rearing) born with atypical genitalia (Prader rating of 3-5 in 46,XX DSD or by a Quigley rating of 3-6 in 46,XY DSD or 45,XO/46,XY) were included in the study. RESULTS There were no significant changes in level of depressive or anxious symptoms or quality of life between baseline and 6-month post-operative follow-up, although mothers continued to report significantly higher levels of depressive symptoms than fathers, and as a group, these parents reported lower QOL than published norms. The level of PTSS significantly decreased for all parents, suggesting that parents may have come through the acute stress phase associated with their child's diagnosis. Finally, while there were no significant changes in IU over the time period, the level of IU for parents of boys actually increased, while parents of girls reported no change (Figure). CONCLUSION Six months after their child has undergone genitoplasty, the majority of parents report minimal levels of psychological distress. However, a subset of these parents continue to experience significant distress related to their child's diagnosis. Specifically, parents of boys appear to be at increased risk for difficulties, which may be related to either the lack of clinical diagnosis for almost half of these children or the necessity of two-stage surgeries for the majority of them. We will continue collecting data on these families to better understand the trajectory of these adjustment variables.
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Affiliation(s)
- Cortney Wolfe-Christensen
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Children's Hospital of Michigan, Detroit, MI, USA.
| | - Amy B Wisniewski
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Kristy J Reyes
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Paul Austin
- St. Louis Children's Hospital, St. Louis, MO, USA
| | - Laurence Baskin
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Kerlly Bernabé
- New York Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Earl Cheng
- Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Allyson Fried
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | | | - Denise Galan
- New York Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Lynette Gonzalez
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | | | - Thomas Kolon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Kropp
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Sabrina Meyer
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - Theresa Meyer
- Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Blake Palmer
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
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45
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Ediati A, Juniarto AZ, Birnie E, Okkerse J, Wisniewski A, Drop S, Faradz SMH, Dessens A. Social stigmatisation in late identified patients with disorders of sex development in Indonesia. BMJ Paediatr Open 2017; 1:e000130. [PMID: 29637149 PMCID: PMC5862183 DOI: 10.1136/bmjpo-2017-000130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/21/2017] [Accepted: 08/22/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess social stigmatisation related to atypical appearance of the body, including, but not limited to the external genitalia, among Indonesian patients with a disorder of sex development (DSD). Until recently, diagnostic evaluation, information about the underlying causes of DSD and treatment options were sparsely available for these patients. METHODS Eighty-one parents of children and adolescents with DSD (aged 6-17 years) and 34 adult patients with DSD (aged 18-41 years) completed the Social Stigmatisation Scale towards DSD, an instrument developed to assesses the frequency of stigmatisation and the level of stress associated with these experiences. Open-ended questions investigated detailed information on stigmatisation as well as parents' and patients' emotional and behavioural reactions to these experiences. Differences in stigmatisation were explored across sex of rearing, gender change history, treatment status and DSD characteristics that could be easily identified by others (e.g., masculinisation of the body in women). RESULTS Social stigmatisation was reported by patients with atypical appearance of their genitalia, atypical appearance of their body aside from their genitals, among those who displayed cross-gender behaviour and those who changed gender. Among participants reared as women and among children and adolescents who changed gender, social stigmatisation was associated with ostracism, depressive symptoms and social isolation. CONCLUSIONS Patients unable to conceal their condition (those with visible physical atypicality and those who changed gender) experienced social stigmatisation. Stigmatisation was stressful and related to isolation and withdrawal from social interaction. Education about DSD, self-empowerment and medical interventions to prevent atypical physical development may remove barriers to acceptance by others for affected individuals.
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Affiliation(s)
- Annastasia Ediati
- Faculty of Psychology, Diponegoro University, Semarang, Indonesia.,Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia
| | - A Zulfa Juniarto
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia.,Dr. Kariadi Hospital, Semarang, Indonesia
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jolanda Okkerse
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Amy Wisniewski
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Stenvert Drop
- Department of Pediatrics, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Sultana M H Faradz
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Jawa Tengah, Indonesia
| | - Arianne Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC Sophia, Rotterdam, The Netherlands
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