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Johnson EK, Whitehead J, Cheng EY. Differences of Sex Development: Current Issues and Controversies. Urol Clin North Am 2023; 50:433-446. [PMID: 37385705 DOI: 10.1016/j.ucl.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Differences of sex development (DSD) encompass a broad range of conditions in which the development of chromosomal, gonadal, or anatomic sex is not typically male or female. Terms used to describe DSD are controversial, and continuously evolving. An individualized, multidisciplinary approach is key to both the diagnosis and management of DSD. Recent advances in DSD care include expanded genetic testing options, a more nuanced approach to gonadal management, and an emphasis on shared decision-making, particularly related to external genital surgical procedures. The timing of DSD surgery is currently being questioned and debated in both medical and advocacy/activism spheres.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA.
| | - Jax Whitehead
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 86, Chicago, IL 60611, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA
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2
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Zwayne N, Chawla R, van Leeuwen K. Caring for Patients With Congenital Adrenal Hyperplasia Throughout the Lifespan. Obstet Gynecol 2023; 142:257-268. [PMID: 37473408 DOI: 10.1097/aog.0000000000005263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 07/22/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting cortisol and aldosterone biosynthesis, which can lead to virilization in fetuses with a 46,XX karyotype. 21-hydroxylase deficiency is the most common cause of CAH, accounting for 90-99% of all patients with the condition. The management of patients with CAH should be done with a multidisciplinary team, which would address all of the complex components of their care throughout their lifespans. Many multidisciplinary teams have adopted shared decision-making approaches to genital surgery in which parents and patients can be part of the decision-making process. Continued research is needed to best serve these patients throughout their lifespans.
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Affiliation(s)
- Noor Zwayne
- Division of Pediatric and Adolescent Gynecology, Women's Health Department, University of Texas at Austin, Dell Medical School, Austin, Texas; and the Division of Pediatric Endocrinology and the Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
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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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Abdelghaffar S, AbdelMoneam EN, Hassanein SA, Radwan NA, Mira MF. Categorization of differences of sex development among Egyptian children and the role of antimullerian hormone and inhibin B. Front Endocrinol (Lausanne) 2023; 13:1072399. [PMID: 36686446 PMCID: PMC9858568 DOI: 10.3389/fendo.2022.1072399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 01/07/2023] Open
Abstract
Background Differences of sex development (DSD) are congenital conditions linked to atypical development of chromosomal, gonadal, or anatomical sex. Objective The aim of this study was to demonstrate our experiences at the Diabetes Endocrine and Metabolism Pediatric Unit (DEMPU), Faculty of Medicine, Cairo University in the field of DSD by focusing on the clinical presentation, laboratory profile, classification, and etiological diagnosis of these conditions. In addition, the present study intended to delineate the importance of serum anti-Müllerian hormone (AMH) and inhibin B in detecting the presence of functioning testicular tissue. Methods This cohort study included 451 infants and children with various clinical presentations of DSD. The study performed a retrospective analysis on medical records of established DSD cases to evaluate the clinical importance of AMH and inhibin B. In addition, newly diagnosed patients were prospectively analyzed. Results Three hundred thirty-six (74.5%) patients were 46,XY DSD, 98 (21.7%) were 46,XX DSD, 14 patients had other karyotypes and 3 had missing karyotypes. Among the 46XY DSD patients, the most common cause was partial androgen insensitivity. In contrast, congenital adrenal hyperplasia constituted the most common diagnosis in 46,XX DSD cases. The cut off value of serum AMH was 14.5 ng/ml with 100% sensitivity and 55.1% specificity. Conclusion Partial androgen insensitivity was the most important cause of 46,XY DSD in Egyptian children, and congenital adrenal hyperplasia was the most common cause of 46,XX DSD. AMH was valuable in detecting functioning testicular tissue.
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Affiliation(s)
- Shereen Abdelghaffar
- The Diabetes, Endocrine and Metabolism Pediatric Unit, Pediatric Department (DEMPU), Cairo University, Cairo, Egypt
| | - Engy Nasr AbdelMoneam
- The Diabetes, Endocrine and Metabolism Pediatric Unit, Pediatric Department (DEMPU), Cairo University, Cairo, Egypt
| | - Samah A. Hassanein
- The Diabetes, Endocrine and Metabolism Pediatric Unit, Pediatric Department (DEMPU), Cairo University, Cairo, Egypt
| | | | - Marwa Farouk Mira
- The Diabetes, Endocrine and Metabolism Pediatric Unit, Pediatric Department (DEMPU), Cairo University, Cairo, Egypt
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5
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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: 662] [Impact Index Per Article: 331.0] [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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7
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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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Sewell R, Buchanan CL, Davis S, Christakis DA, Dempsey A, Furniss A, Kazak AE, Kerlek AJ, Magnusen B, Pajor NM, Pyle L, Pyle LC, Razzaghi H, Schwartz BI, Vogiatzi MG, Nokoff NJ. Behavioral Health Diagnoses in Youth with Differences of Sex Development or Congenital Adrenal Hyperplasia Compared with Controls: A PEDSnet Study. J Pediatr 2021; 239:175-181.e2. [PMID: 34461062 PMCID: PMC8604751 DOI: 10.1016/j.jpeds.2021.08.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the odds of a behavioral health diagnosis among youth with differences of sex development (DSD) or congenital adrenal hyperplasia (CAH) compared with matched controls in the PEDSnet database. STUDY DESIGN All youth with a diagnosis of DSD (n = 1216) or CAH (n = 1647) and at least 1 outpatient encounter were extracted from the PEDSnet database and propensity-score matched on 8 variables (1:4) with controls (n = 4864 and 6588, respectively) using multivariable logistic regression. The likelihood of having behavioral health diagnoses was examined using generalized estimating equations. RESULTS Youth with DSD had higher odds of a behavioral health diagnosis (OR, 1.7; 95% CI, 1.4-2.1; P < .0001) and neurodevelopmental diagnosis (OR, 1.7; 95% CI, 1.4, 2.0; P < .0001) compared with matched controls. Youth with CAH did not have an increased odds of a behavioral health diagnosis (OR, 1.0; 95% CI, 0.9, 1.1; P = .9) compared with matched controls but did have higher odds of developmental delay (OR, 1.8; 95% CI, 1.4, 2.4; P < .0001). CONCLUSIONS Youth with DSD diagnosis have higher odds of a behavioral health or neurodevelopmental diagnosis compared with matched controls. Youth with CAH have higher odds of developmental delay, highlighting the need for screening in both groups.
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Affiliation(s)
- Rachel Sewell
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Shanlee Davis
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Dimitri A Christakis
- Seattle Children's Research Institute, Center for Child Health, Behavior & Development, Seattle, WA
| | | | - Anna Furniss
- University of Colorado Anschutz Medical Campus, Adult & Child Consortium for Health Outcomes Research & Delivery, Aurora, CO
| | - Anne E Kazak
- Nemours Children's Health, Department of Pediatrics, Center for Healthcare Delivery Science and Thomas Jefferson University, Wilmington, DE
| | - Anna J Kerlek
- Department of Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, OH
| | - Brianna Magnusen
- Nationwide Children's Hospital, Institute for Informatics, Columbus, OH
| | - Nathan M Pajor
- Cincinnati Children's Hospital Medical Center, Division of Pulmonary Medicine and University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH
| | - Laura Pyle
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Louise C Pyle
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hanieh Razzaghi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Beth I Schwartz
- Nemours Children's Health, Department of Pediatrics and Thomas Jefferson University, Department of Obstetrics and Gynecology, Wilmington, DE
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie J Nokoff
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Bennecke E, Köhler B, Röhle R, Thyen U, Gehrmann K, Lee P, Nordenström A, Cohen-Kettenis P, Bouvattier C, Wiesemann C. Disorders or Differences of Sex Development? Views of Affected Individuals on DSD Terminology. JOURNAL OF SEX RESEARCH 2021; 58:522-531. [PMID: 31985272 DOI: 10.1080/00224499.2019.1703130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Over a decade ago, the participants at the International Consensus Conference on Intersex proposed Disorders of Sex Development (DSD) as an umbrella term for "congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical". The Group recommended the terminology be sensitive to concerns of individuals having these conditions. Yet, controversy rages over the term DSD. This multicentre clinical evaluation study was initiated as part of the European research group dsd-LIFE to evaluate patient-reported outcome. In total, 1,040 individuals with conditions labeled as Disorders of Sex Development were recruited in Poland, Sweden, Germany, France, United Kingdom and the Netherlands. All participants were asked to rate the terms describing their conditions. Overall, a large majority of participants (69%) reported that the term Disorders of Sex Development applied to their condition or that they felt neutral about it. Most participants preferred terms that were specific to their somatic condition. Overall, our data do not support the view that, in general, the term Disorders of Sex Development is insensitive to concerns of affected persons and that it should therefore be abandoned. However, in the clinical encounter, we recommend that clinicians evaluate each patient's preferences.
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Affiliation(s)
- Elena Bennecke
- Sozialpädiatrisches Zentrum (SPZ), Center for Chronically Sick Children, Charité University Medicine
| | - Birgit Köhler
- Department of Paediatrics, Division of Endocrinology and Diabetology, Charité University Medicine
| | - Robert Röhle
- Koordinierungszentrum Klinische Studien (KKS), University Medicine
| | - Ute Thyen
- Hospital for Children and Adolescents, University of Lübeck
| | - Katharina Gehrmann
- Department of Paediatrics, Division of Endocrinology and Diabetology, Charité University Medicine
| | - Peter Lee
- Department of Paediatrics, Penn State College of Medicine
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital
| | | | | | - Claudia Wiesemann
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen
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Szymanski KM, Rink RC, Whittam B, Hensel DJ. Majority of females with a life-long experience of CAH and parents do not consider females with CAH to be intersex. J Pediatr Urol 2021; 17:210.e1-210.e9. [PMID: 33041207 DOI: 10.1016/j.jpurol.2020.09.009] [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: 07/09/2020] [Revised: 09/04/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION To assess opinions of females with CAH, and parents of females with CAH, about designating this population "intersex," particularly in legislation about genital surgery during childhood. METHODS We conducted a mixed-methods (quantitative and qualitative) anonymous cross-sectional online survey of females with CAH (46XX, 16+years old) and independently recruited parents of girls with CAH (2019-2020) diagnosed in first year of life from the United States. A multidisciplinary CAH team drafted the survey in collaboration with women with CAH and parents. Fisher's exact test was used to compare female and parent responses. A qualitative thematic approach was used to analyze open-ended answers for emergent categories of reasons why CAH females should or should not be considered as intersex. RESULTS Of 57 females with CAH participating (median age: 39 years, 75.5% of ≥25year olds had post-secondary degree), all had classical CAH and 93.0% underwent genital surgery at median 1-2 years old. While 89.5% did not endorse the intersex designation for CAH, the remaining 5.3% did (5.3% provided no answer, Summary Figure). Most CAH females (63.2%) believed CAH females should be considered separately in "any laws banning or allowing surgery of children's genitals" (19.3% disagreed, 17.5% neutral, 0.0% no answer). Most common themes identified by females with CAH not endorsing an intersex designation were: normal female internal organs, sex chromosomes, personal identity, genital appearance, issues with language, hormones, and those endorsing it: genital appearance, community/group experiences, topic complexity. Overall, 132 parents of females with CAH participated (parent/child median ages: 40/11 years, 81.7% of ≥25year olds had post-secondary degree). All children had classical CAH and 78.8% underwent surgery at median <1 year old. While 95.5% of parents did not endorse the intersex designation for CAH, 2.3% did (2.3% no answer), similar to females (p = 0.29). Most parents (81.1%) believed CAH females should be considered separately in legislation (9.1% disagreed, 6.1% neutral, 3.8% no answer), a slightly higher percentage than females (p = 0.01). DISCUSSION Echoing previously published disagreement with clinically designating CAH females as intersex, majority of CAH females and parents oppose a legal intersex designation. Differing opinions among females and parents strengthen concern about a one-size-fits-all approach to legislation about childhood genital surgery. Differences in opinions between female and parent responses, while statistically significant, were relatively small. CONCLUSION Majority of females with CAH and parents believe CAH should be excluded from the intersex designation, and should be considered separately in legislation pertaining to childhood genital surgery.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA.
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Devon J Hensel
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine and Department of Sociology, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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11
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Shiryaev ND, Kagantsov IM, Sizonov VV. [Disorders of sex differentiation: state of the problem 15 years after the Chicago consensus]. PROBLEMY ENDOKRINOLOGII 2020; 66:70-80. [PMID: 33351341 DOI: 10.14341/probl12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 06/12/2023]
Abstract
It is well known that the nomenclature and classification were changed in 2005 at the international consensus conference on intersex disorders, held in Chicago, where, among others, the following recommendations were proposed: (1) all children should be assigned a gender identity, and this should be done as quickly as possible, taking into account the time required for the examination. (2) all infants with congenital adrenal hyperplasia and 46,XX karyotype, including those with pronounced masculinization, must be raised as women. (3) Surgical treatment should be performed early and in cases of feminizing genitoplasty, clitoral reduction should be performed simultaneously with reconstruction of the urogenital sinus (separation of the vagina and urethra). An analysis of contemporary literature shows that all these theories, proposed 15 years ago at the Chicago meeting, failed to stand the test of time. New nomenclature and classification are constantly being revised. Currently, many groups of patients want to abolish the term «sexual maturity disorders.» Recommendations regarding gender reassignment and appropriate early surgical treatment have been completely ignored in some countries. All this was largely facilitated by the confrontational activities of a number of support groups.
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Affiliation(s)
| | - Ilya M Kagantsov
- Pitirim Sorokin Syktyvkar State University; Republican Children's Clinical Hospital
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12
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García-Acero M, Moreno O, Suárez F, Rojas A. Disorders of Sexual Development: Current Status and Progress in the Diagnostic Approach. Curr Urol 2020; 13:169-178. [PMID: 31998049 DOI: 10.1159/000499274] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/14/2018] [Indexed: 12/13/2022] Open
Abstract
Disorders of sexual development (DSD) are conditions with an atypical chromosomal, gonadal or phenotypic sex, which leads to differences in the development of the urogenital tract and different clinical phenotypes. Some genes have been implicated in the sex development during gonadal and functional differentiation where the maintenance of the somatic sex of the gonad as either male or female is achieved by suppression of the alternate route. The diagnosis of DSD requires a structured approach, involving a multidisciplinary team and different molecular techniques. We discuss the dimorphic genes and the specific pathways involved in gonadal differentiation, as well as new techniques for genetic analysis and their diagnostic value including epigenetic mechanisms, expanding the evidence in the diagnostic approach of individuals with DSD to increase knowledge of the etiology.
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Affiliation(s)
- Mary García-Acero
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Olga Moreno
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Fernando Suárez
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Adriana Rojas
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
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13
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Szymanski KM, Salama AK, Whittam B, Frady H, Cain MP, Rink RC. Beyond changing diapers: stress and decision-making among parents of girls with congenital adrenal hyperplasia seeking consultation about feminizing genital restoration surgery. J Pediatr Urol 2019; 15:653-658. [PMID: 31685391 DOI: 10.1016/j.jpurol.2019.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION/BACKGROUND The impact of having a child with atypical genitalia due to a life-threating chronic medical condition like congenital adrenal hyperplasia (CAH) is poorly understood. OBJECTIVE The aim of the study was to determine parental stress and impact of CAH on parental decisions, including decisions regarding female genital restoration surgery (FGRS). STUDY DESIGN The authors surveyed consecutive parents of girls with CAH ≤3 years presenting at a tertiary referral center for FGRS consultation (2016-2019). The survey was developed by three families of daughters with CAH and six clinicians. Nine potentially stressful past experiences were rated on a 6-point Likert scale ('not at all' to 'extremely' stressful). Overall parental stress and strain (broader negative consequences) were reported using validated instruments (Perceived Stress Scale and Caregiver Strain Questionnaire Short Form, respectively). Impact of CAH on past decisions about childcare, social interactions, and who changes diapers were also assessed. Non-parametric tests were used for analysis. RESULTS Twenty-nine parents (median age: 32years) of 22 consecutive children participated (Prader 3/4/5: 59.1%/36.4%/4.5%). After the study, 20 girls (90.9%) underwent FGRS at a median age of 8 months. The most stressful experiences were having an adrenal crisis ('very much' stressful), waiting for the CAH diagnosis, and making sense of the diagnosis (both 'quite a bit') (Figure 1). Remaining issues were 'somewhat' stressful. Deciding whether to proceed with FGRS was ranked as the least stressful issue. Overall parental stress was similar to overall stress previously reported by spousal caregivers of stroke or heart failure survivors (P ≥ 0.15). Overall parental strain was similar to parents of adolescents receiving mental health counseling (P = 0.77). Congenital adrenal hyperplasia impacted decisions about babysitting, daycare, who changed diapers, and choosing a pediatrician (P ≤ 0.02), but did not impact parental social interactions (P ≥ 0.11). Diapers were typically changed by parents (100.0%) and grandmothers (50.0%). Parents anticipated that some individuals currently not allowed to change diapers would be allowed after FGRS: grandfathers (+18.2%), aunts/uncles (+27.3-32.8%), cousins (+18.2%), and family friends (+45.5%). DISCUSSION The authors present the first assessment of parental stress with respect to different aspects of care of a daughter with CAH. Larger studies are required to determine if the parental stress associated with these experiences varies over time and how these stressors rank relative to each other through the child's development. CONCLUSION Parents experience multiple stressors after having a daughter with CAH. Parental stress surrounding a decision about FGRS appears less severe than events pertaining to the diagnosis and medical management of CAH. Congenital adrenal hyperplasia impacts multiple parental decisions.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA.
| | - Amr K Salama
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Heather Frady
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Mark P Cain
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
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Carpenter M. Intersex Variations, Human Rights, and the International Classification of Diseases. Health Hum Rights 2018; 20:205-214. [PMID: 30568414 PMCID: PMC6293350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Over time, the World Health Organization (WHO) has reviewed and removed pathologizing classifications and codes associated with sexual and gender minorities from the International Classification of Diseases (ICD). However, classifications associated with intersex variations, congenital variations in sex characteristics or differences of sex development, remain pathologized. The ICD-11 introduces additional and pathologizing normative language to describe these as "disorders of sex development." Current materials in the ICD-11 Foundation also specify, or are associated with, unnecessary medical procedures that fail to meet human rights norms documented by the WHO itself and Treaty Monitoring Bodies. This includes codes that require genitoplasties and gonadectomies associated with gender assignment, where either masculinizing or feminizing surgery is specified depending upon technical and heteronormative expectations for surgical outcomes. Such interventions lack evidence. Human rights defenders and institutions regard these interventions as harmful practices and violations of rights to bodily integrity, non-discrimination, equality before the law, privacy, and freedom from torture, ill-treatment, and experimentation. WHO should modify ICD-11 codes by introducing neutral terminology and by ensuring that all relevant codes do not specify practices that violate human rights.
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Affiliation(s)
- Morgan Carpenter
- Senior advisor at GATE, a co-executive director of Intersex Human Rights Australia, and a graduate and PhD candidate in bioethics at Sydney Health Ethics in the Faculty of Medicine and Health, University of Sydney, Australia. This article was produced in the context of the GATE initiative on the process of revision and reform of the International Classification of Diseases
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15
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Surgery of Anomalies of Gonadal and Genital Development in the “Post-Truth Era”. Urol Clin North Am 2018; 45:659-669. [DOI: 10.1016/j.ucl.2018.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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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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Kim S, Rosoklija I, Johnson EK. Surgical, Patient, and Parental Considerations in the Management of Children with Differences of Sex Development. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Lundberg T, Hegarty P, Roen K. Making sense of ‘Intersex’ and ‘DSD’: how laypeople understand and use terminology. PSYCHOLOGY & SEXUALITY 2018. [DOI: 10.1080/19419899.2018.1453862] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Tove Lundberg
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Peter Hegarty
- School of Psychology, University of Surrey, Guildford, England
| | - Katrina Roen
- Department of Psychology, University of Oslo, Oslo, Norway
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González R, Ludwikowski BM. Is It Beneficial to Patients to Include Congenital Adrenal Hyperplasia (CAH) Among the Disorders of Sex Development (DSD)? Front Pediatr 2018; 6:344. [PMID: 30483487 PMCID: PMC6240692 DOI: 10.3389/fped.2018.00344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Kinder-und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Kinder-und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
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Johnson EK, Rosoklija I, Finlayson C, Chen D, Yerkes EB, Madonna MB, Holl JL, Baratz AB, Davis G, Cheng EY. Response to 'Re. Attitudes towards disorders of sex development nomenclature among affected individuals'. J Pediatr Urol 2017; 13:610-611. [PMID: 28552319 DOI: 10.1016/j.jpurol.2017.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Arlene B Baratz
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, Duncan, OK, USA; Department of Radiology, Temple University School of Medicine, Pittsburgh, PA, USA
| | - Georgiann Davis
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, Duncan, OK, USA; Department of Sociology, University of Nevada, Las Vegas, NV, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Johnson EK, Rosoklija I, Finlayson C, Chen D, Yerkes EB, Madonna MB, Holl JL, Baratz AB, Davis G, Cheng EY. Attitudes towards "disorders of sex development" nomenclature among affected individuals. J Pediatr Urol 2017; 13:608.e1-608.e8. [PMID: 28545802 DOI: 10.1016/j.jpurol.2017.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Although now commonly used in medicine, the updated "disorders of sex development" (DSD) nomenclature formally introduced in 2006 has never been universally accepted by members of the affected community, particularly advocacy groups. Use of this nomenclature by medical professionals may unintentionally negatively affect access to healthcare and research for individuals with DSD conditions. OBJECTIVE Among individuals affected by various DSD diagnoses, this study sought to (1) evaluate attitudes towards potentially controversial DSD terminology, (2) determine potential impact of terminology on how affected individuals access healthcare, and (3) explore alternate terms. STUDY DESIGN A web-based survey was developed in collaboration with the AIS-DSDSG (Androgen Insensitivity Syndrome-DSD Support Group) leadership. AIS-DSDSG members (caregivers and affected individuals) were surveyed about attitudes towards DSD, potential impact on healthcare utilization, and alternate terms. A qualitative analysis of reasons for using/avoiding specific terms was performed. RESULTS Surveys were completed by 202 out of 580 (35%) AIS-DSDSG members (61% affected, 39% caregivers; 16% non-gender binary; age range of affected individuals 0-86 years). Only 24% use disorder of sex development to describe themselves/their child. A majority (69%) had a negative emotional experience because of clinical use of nomenclature; 81% changed their care because of it. Preferred and non-preferred terms for clinical care and research are illustrated in the figure. Preferred diagnostic terms were intersex, variation in sex development, and difference of sex development (55%, 52%, and 50% liked/strongly liked, respectively). Disorder of sex development was not preferred (17% liked/strongly liked). About one-third reported that they would not attend a clinic named the Disorder of Sex Development Clinic. Overall, 81% provided qualitative comments; flexible terminology use was a key theme. DISCUSSION These study findings are consistent with previous studies that demonstrated negative perceptions of DSD nomenclature. This study adds to previous findings by surveying a large group of affected individuals with a range of diagnoses, and by exploring emotional impact and healthcare utilization. Several possible alternative terms were also defined. The study was limited by inclusion of only members of AIS-DSDSG, a convenience sample where complete AIS is over-represented, and whose views may not represent the opinion of all individuals with DSD conditions. CONCLUSIONS A group of affected individuals and parents have negative views about the DSD terminology commonly used by medical professionals. Use of certain terms may affect the choice of healthcare provider/institution. Evaluation of DSD terminology in other affected individuals, and re-evaluation of current nomenclature, in collaboration with advocates, is needed.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Courtney Finlayson
- Division Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Arlene B Baratz
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, University of Nevada, Las Vegas, NV, USA; Department of Radiology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Georgiann Davis
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, University of Nevada, Las Vegas, NV, USA; Department of Sociology, University of Nevada, Las Vegas, NV, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Mouriquand P. Commentary to "Attitudes towards 'disorders of sex development' nomenclature among affected". J Pediatr Urol 2017; 13:609. [PMID: 28669585 DOI: 10.1016/j.jpurol.2017.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Pierre Mouriquand
- Hôpital Mère-Enfant - Hospices Civils de Lyon Université Claude-Bernard Bron, France.
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Recommendations for the Establishment of Disorders/Differences of Sex Development Interdisciplinary Care Clinics for Youth. J Pediatr Nurs 2017; 37:79-85. [PMID: 28888337 DOI: 10.1016/j.pedn.2017.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Provide recommendations for the development of an interdisciplinary care (IDC) clinic for the treatment of youth with disorders/differences of sex development (DSD). DSD consist of a group of complex congenital medical disorders in which the development of chromosomal, gonadal, or anatomical sex is atypical. Youth with DSD require care from multiple specialized healthcare disciplines, including several medical specialties, surgery, nursing, and mental health. METHOD Recommendations are based on an interdisciplinary care clinic model that allows for a team of relevant professionals who share knowledge, ideas, and responsibility of care. The framework established in this article is based largely on experiences at an established DSD clinic, as well as observations of multiple clinics across the United States. RESULTS Preliminary outcome data on clinic adherence to treatment protocol under an IDC model are provided. CONCLUSIONS To meet the diverse healthcare needs of youth with DSD, comprehensive care clinics are recommended; however, few such clinics exist in the United States. Establishing new comprehensive DSD clinics can be challenging due to the highly unique treatment of DSD, but the current paper expands the literature available to guide clinic development in the United States.
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Fleming L, Knafl K, Van Riper M. How the Child's Gender Matters for Families Having a Child With Congenital Adrenal Hyperplasia. JOURNAL OF FAMILY NURSING 2017; 23:516-533. [PMID: 29046104 DOI: 10.1177/1074840717735499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Children with congenital adrenal hyperplasia (CAH) are exposed to high levels of testosterone in utero often resulting in nontypical genitalia at birth for girls. The purpose of this analysis, which draws on data from a larger study, was to examine, based on the gender of the child, the family experiences of having a child with CAH. Sixteen parents were interviewed, and comparisons were made across all categories coded in the parents' interviews to examine similarities and differences in the experiences of families based on the child's gender. Families having a daughter with CAH experienced additional challenges when compared with families having a son. These include fear of stigmatization, challenging surgical decisions, and concerns regarding disclosure of the condition. Acknowledging this and creating support programs tailored for girls that address surgical procedures and complications resulting from being born with elevated testosterone are critical to promoting a healthy family and child response.
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Affiliation(s)
- Louise Fleming
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
| | - Kathleen Knafl
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
| | - Marcia Van Riper
- 1 University of North Carolina at Chapel Hill School of Nursing, USA
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25
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Abstract
Female patients with congenital adrenal hyperplasia (CAH) have varying degrees of atypical genitalia secondary to prenatal and postnatal androgen exposure. Surgical treatment is focused on restoring normal genitalia anatomy by bringing the vagina to the normal position on the perineum, separating the distal vagina from the urethra, forming a normal introitus and preserving sexual function of the clitoris by accepting moderate degrees of hypertrophy as normal and strategically reducing clitoral size only in the most severely virilized patients. There remains a need for continued monitoring of patients as they go through puberty with the possibility of additional surgery for vaginal stenosis. Anatomically based surgery and refinement in surgical techniques with acceptance of moderate degrees of clitoral hypertrophy as normal should improve long-term outcomes.
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Affiliation(s)
- Laurence S Baskin
- UCSF Benioff Children's Hospital, 1825 Fourth St, 5th Floor, San Francisco, CA 94143.
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26
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Bennecke E, Thyen U, Grüters A, Lux A, Köhler B. Health-related quality of life and psychological well-being in adults with differences/disorders of sex development. Clin Endocrinol (Oxf) 2017; 86:634-643. [PMID: 28005277 DOI: 10.1111/cen.13296] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/17/2016] [Accepted: 12/14/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Rare congenital conditions with incongruence of chromosomal, gonadal and phenotypic sex have been classified as differences/disorders of sex development (DSD). Included in DSD are conditions with diverse genetic aetiology, varying levels of prenatal androgen effects, phenotypes and, subsequently, different medical treatments. Quality of life (QoL) and psychological well-being are indicators of successful psychosocial adaptation to the conditions. We sought to investigate the HRQoL and psychological well-being in this population. DESIGN This multicentre clinical evaluation study was part of a German network related to DSD funded by the German Ministry of Science and Education (BMBF 2003 to 2007). METHODS To assess health-related quality of life (HRQoL), we used the Short Form Health Survey (SF-36), and for psychological well-being, the Brief Symptom Inventory (BSI). Participants were classified into five groups: females with CAH, females with XY DSD conditions where there is a partial androgen effect (partial androgen insensitivity, mixed/partial gonadal dysgenesis, disorders of androgen biosynthesis), females with XY DSD without androgen effect (complete androgen insensitivity, complete gonadal dysgenesis), males with XY DSD, and individuals with DSD conditions and other gender. RESULTS Participants included 110 adults with DSD (age range 17-62). We found a trend of lowered mental HRQoL and significant higher physical HRQoL for participants as compared to the norm. The high physical HRQoL especially applied to females with androgen effect and XY karyotype. Participants reported significant higher psychological distress compared to the norm. Forty-seven participants (42·7%) reported distress in a clinically relevant range on the BSI. CONCLUSIONS Although we did not find significant impairments in overall HRQoL, participants reported significant impaired psychological well-being. Specialized interdisciplinary care should focus in particular on psychological issues to ensure good overall health and well-being.
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Affiliation(s)
- Elena Bennecke
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
| | - Ute Thyen
- Hospital for Children and Adolescents, University of Lübeck, Lübeck, Germany
| | - Annette Grüters
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
| | - Anke Lux
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Birgit Köhler
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- Division of Gender, Sexuality, and Health, New York State Psychiatric Institute/Department of Psychiatry, College of Physicians & Surgeons of Columbia University , New York, New York
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Jenkins TM, Short SE. Negotiating intersex: A case for revising the theory of social diagnosis. Soc Sci Med 2017; 175:91-98. [PMID: 28073070 PMCID: PMC5293660 DOI: 10.1016/j.socscimed.2016.12.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 12/22/2016] [Accepted: 12/30/2016] [Indexed: 11/29/2022]
Abstract
The theory of social diagnosis recognizes two principles: 1) extra-medical social structures frame diagnosis; and 2) myriad social actors, in addition to clinicians, contribute to diagnostic labels and processes. The relationship between social diagnosis and (de)medicalization remains undertheorized, however, because social diagnosis does not account for how social actors can also resist the pathologization of symptoms and conditions-sometimes at the same time as they clamor for medical recognition-thereby shaping societal definitions of disease in different, but no less important, ways. In this article, we expand the social diagnosis framework by adding a third principle, specifically that 3) social actors engage with social structures to both contribute to, and resist, the framing of a condition as pathological (i.e. medicalization and demedicalization). This revised social diagnosis framework allows for the systematic investigation of multi-directional, dynamic processes, formalizing the link between diagnosis and (de)medicalization. It also responds to long-standing calls for more contextualized research in (de)medicalization studies by offering a framework that explicitly accounts for the social contexts in which (de)medicalizing processes operate. To showcase the utility of this revised framework, we use it to guide our analyses of a highly negotiated diagnosis: intersex.
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Affiliation(s)
- Tania M Jenkins
- Department of Sociology, University of Chicago, 1126 East 59th Street, Chicago, IL 60637, USA.
| | - Susan E Short
- Department of Sociology, Brown University, Box 1916, Maxcy Hall, 112 George Street, Providence, RI 02912, USA.
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29
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Alpert AB, CichoskiKelly EM, Fox AD. What Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Patients Say Doctors Should Know and Do: A Qualitative Study. JOURNAL OF HOMOSEXUALITY 2017; 64:1368-1389. [PMID: 28481724 PMCID: PMC6947913 DOI: 10.1080/00918369.2017.1321376] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This qualitative study explored the experiences of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people in health care and their recommendations for physicians. Six focus groups were conducted with LGBTQI people (N = 48) in four U.S. cities between October 2013 and April 2014. Five overarching themes emerged regarding patients' suggestions for providers: be comfortable with LGBTQI patients; share medical decision-making; avoid assumptions; apply LGBTQI-related knowledge; and address the social context of health disparities. These core competencies differed in meaningful ways from competencies created by national organizations such as the Association of American Medical Colleges. Community-derived competencies1 stressed the importance of collaborative patient-physician partnerships, particularly in the setting of hormone prescription for transgender patients, and prioritized addressing social determinants of health and focusing on marginalized subpopulations2 and stigmatized needs of the community. Limitations, particular of sampling, were considered. Community input could improve medical education interventions to reduce health disparities in marginalized communities.
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Affiliation(s)
- Alison B Alpert
- a Larner College of Medicine , University of Vermont , Burlington , Vermont , USA
| | - Eileen M CichoskiKelly
- b Department of Family Medicine , Larner College of Medicine, University of Vermont , Burlington , Vermont , USA
| | - Aaron D Fox
- c Division of General Internal Medicine, Montefiore Medical Center , Bronx , New York , USA
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Wang LC, Poppas DP. Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know. J Steroid Biochem Mol Biol 2017; 165:137-144. [PMID: 26995108 DOI: 10.1016/j.jsbmb.2016.03.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Abstract
Surgical management of classical congenital adrenal hyperplasia (CAH) in 46, XX females has evolved significantly. Virilization of the genitalia of 46, XX females with CAH begins prenatally as a result of excess fetal androgen production. Improved understanding of anatomy and surgical outcomes has driven changes in surgical techniques as well as the timing of surgery. For endocrinologists treating these patients, it is important to understand the outcome of genitoplasty, identify patients who need further treatment and direct these patients to experienced surgeons. We performed a literature search on PubMed of publications addressing CAH and genital reconstruction published in the English language from 1990 to the present. In accordance with our institutional review board, we performed a retrospective analysis of clitoroplasty and/or vaginoplasty procedures performed by a single surgeon at our institution from 1996 to 2015. We found that genital reconstruction in 46, XX CAH patients is associated with few immediate post-operative, infectious, and urinary complications. Vaginal stenosis is a common complication of vaginal reconstruction and requires evaluation by an experienced surgeon. Clitoral pain or decreased sensation can be associated with clitoral recession and clitorectomy. Outcomes in sexual satisfaction and gender identity can also be impacted by surgical technique and success. Long term follow up and patient reported feedback are crucial to our understanding and management of this special group of patients. Improved awareness and understanding of the complications of genital surgery will allow endocrinologists to know what to ask patients and be ready to provide them with a resource with the understanding and experience to help them improve their quality of life.
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Affiliation(s)
- Lily C Wang
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States.
| | - Dix P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States
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Lee PA, Nordenström A, Houk CP, Ahmed SF, Auchus R, Baratz A, Baratz Dalke K, Liao LM, Lin-Su K, Looijenga LHJ, Mazur T, Meyer-Bahlburg HFL, Mouriquand P, Quigley CA, Sandberg DE, Vilain E, Witchel S. Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care. Horm Res Paediatr 2016; 85:158-80. [PMID: 26820577 DOI: 10.1159/000442975] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022] Open
Abstract
The goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups. The goal of patient care is focused upon the best possible quality of life (QoL). The field of DSD is continuously developing. An update on the clinical evaluation of infants and older individuals with ambiguous genitalia including perceptions regarding male or female assignment is discussed. Topics include biochemical and genetic assessment, the risk of germ cell tumor development, approaches to psychosocial and psychosexual well-being and an update on support groups. Open and on-going communication with patients and parents must involve full disclosure, with the recognition that, while DSD conditions are life-long, enhancement of the best possible outcome improves QoL. The evolution of diagnosis and care continues, while it is still impossible to predict gender development in an individual case with certainty. Such decisions and decisions regarding surgery during infancy that alters external genital anatomy or removes germ cells continue to carry risk.
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Affiliation(s)
- Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pa., USA
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Mouriquand PDE, Gorduza DB, Gay CL, Meyer-Bahlburg HFL, Baker L, Baskin LS, Bouvattier C, Braga LH, Caldamone AC, Duranteau L, El Ghoneimi A, Hensle TW, Hoebeke P, Kaefer M, Kalfa N, Kolon TF, Manzoni G, Mure PY, Nordenskjöld A, Pippi Salle JL, Poppas DP, Ransley PG, Rink RC, Rodrigo R, Sann L, Schober J, Sibai H, Wisniewski A, Wolffenbuttel KP, Lee P. Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how? J Pediatr Urol 2016; 12:139-49. [PMID: 27132944 DOI: 10.1016/j.jpurol.2016.04.001] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/25/2016] [Accepted: 04/04/2016] [Indexed: 01/25/2023]
Abstract
Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.
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Affiliation(s)
- Pierre D E Mouriquand
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France.
| | - Daniela Brindusa Gorduza
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Claire-Lise Gay
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute, New York, NY, USA; College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Linda Baker
- Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laurence S Baskin
- Pediatric Urology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Claire Bouvattier
- Service d'Endocrinologie de l'enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France
| | - Luis H Braga
- Division of Urology, Department of Surgery, McMaster University, Toronto, Canada
| | - Anthony C Caldamone
- Pediatric Urology, Hasbro Children's Hospital, Providence, RI, USA; Surgery (Urology) and Pediatrics, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Lise Duranteau
- Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France; Adolescent Gynaecology, Hôpitaux Universitaires Paris Sud (Bicêtre), Paris, France
| | - Alaa El Ghoneimi
- Pediatric Surgery and Urology, University Hospital Robert Debré, APHP, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Terry W Hensle
- College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Piet Hoebeke
- Urology, Ghent University Hospital, Gent, Belgium
| | - Martin Kaefer
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicolas Kalfa
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Thomas F Kolon
- Pediatric Urology, Children's Hospital of Philadelphia, PA, USA; Perelman School of Medicine at University of Pennsylvania, PA, USA
| | - Gianantonio Manzoni
- Pediatric Urology, Fondazione IRCCS CaGranda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierre-Yves Mure
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - J L Pippi Salle
- Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Dix Phillip Poppas
- Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Philip G Ransley
- Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Richard C Rink
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Romao Rodrigo
- Department of Surgery, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Department of Urology, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Léon Sann
- Conseil d'éthique pédiatrique, Centre Hospitalo-Universitaire de Lyon, France
| | | | - Hisham Sibai
- Paediatric Surgery, University of Casablanca, Morocco
| | | | - Katja P Wolffenbuttel
- Department of Urology and Pediatric Urology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Peter Lee
- Penn State Hershey Pediatric Endocrinology, PA, USA
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33
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Abstract
Great controversies and misunderstandings have developed around the relatively recently coined term disorders of sex development (DSD). In this article, we question the wisdom of including XX individuals with congenital adrenal hyperplasia (CAH) in the DSD category and develop arguments against it based on the published literature on the subject. It is clear that females with CAH assigned the female gender before 24 months of age and properly managed retain the female gender identity regardless of the Prader grade. Females with CAH and low Prader grades have the potential for a normal sexual and reproductive life. Those with greater degrees of prenatal androgen exposure (Prader grades IV and V) raised as females also identify themselves as females but experience more male-like behavior in childhood, have a greater rate of homosexuality, and have greater difficulty with vaginal penetration and maintaining pregnancies. Improvement in surgical techniques, better endocrinological, psychological, and surgical follow-up may lessen these problems in the future. Given the fact that the term DSD includes many conditions with problematic gender identity and conflicts with the gender assigned at birth, it may be appropriate to exclude females with CAH from the DSD classification.
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Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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