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DeLone AM, Fisher RS, Traino KA, Basile NL, Buchanan CL, Cheng EY, Poppas DP, Baraldi AN, Wisniewski AB, Mullins LL. Exploratory factor analysis of the Illness Intrusiveness Rating Scale for parents of children with atypical genital appearance due to differences of sex development (DSD). J Pediatr Psychol 2024; 49:482-490. [PMID: 38578612 PMCID: PMC11258802 DOI: 10.1093/jpepsy/jsae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE Illness intrusiveness refers to the subjective cognitive appraisal of a chronic health condition interfering in daily, valued activities and may be highly relevant for parents of children with atypical genital appearance due to differences of sex development (DSD). However, a measure of illness intrusiveness has not been validated for this population. The current study aimed to evaluate the factor structure of the Illness Intrusiveness Scale for Parents (IIS-P) and examine convergent validity. METHODS Participants included 102 parents (Mage = 33.39 years, SD = 6.48; 58% mothers) of 65 children (<2 years old) diagnosed with DSD participating in a larger, longitudinal study. Parents completed the IIS-P as well as self-report measures of stigma, and anxious and depressive symptoms. An exploratory factor analysis (EFA) was conducted. RESULTS EFA results supported a 1-factor intrusiveness solution (α = .93), as well as a 2-factor solution measuring intrusiveness on daily living (α = .92) and community connectedness (α = .85). The 1-factor solution and both factors of the 2-factor solution demonstrated significant convergent validity with stigma as well as anxious and depressive symptoms. CONCLUSIONS Support emerged for both 1- and 2-factor solutions of the IIS-P in parents of children with DSD. The decision to evaluate illness intrusiveness as a total score or to examine the subscales of daily living and community connectedness should be tailored to the unique aims of researchers and clinicians. Future research should conduct a confirmatory factor analysis with both 1- and 2-factor models with larger, more diverse samples of caregivers.
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Affiliation(s)
- Alexandra M DeLone
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Rachel S Fisher
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Nathan L Basile
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, United States
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, United States
| | - Dix P Poppas
- James Buchanan Brady Department of Urology, Komansky Children’s Hospital, New York Presbyterian Hospital-Weill Cornell Medicine, New York, United States
| | - Amanda N Baraldi
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, United States
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Basile NL, Dattilo TM, DeLone AM, Kraft JD, Edwards CS, Buchanan CL, Cheng EY, Poppas DP, Wisniewski AB, Mullins LL. Parental Uncertainty Scale Factor Structure in Pediatric DSD With Ambiguous Genitalia. J Pediatr Psychol 2023; 48:386-395. [PMID: 36728708 PMCID: PMC10118853 DOI: 10.1093/jpepsy/jsad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Illness uncertainty is a salient experience for caregivers of children with disorders/differences of sex development (DSD) presenting with ambiguous genitalia; however, no validated measure of illness uncertainty exists for this unique population. Thus, the current study aimed to preliminarily identify the factor structure of the Parental Perception of Uncertainty Scale (PPUS) in caregivers of children with DSD presenting with ambiguous genitalia and examine the convergent validity of the PPUS. METHODS Participants included 115 caregivers (Mage = 32.12 years, SD = 6.54; 57% mothers) of children (<2-year-olds) diagnosed with DSD participating in a larger, longitudinal study. Caregivers completed the PPUS as well as self-report measures of anxious, depressive, and posttraumatic stress symptoms. An exploratory factor analysis was conducted. RESULTS Exploratory factor analysis results indicated that a 23-item 1-factor solution was the most parsimonious and theoretically sound factor structure (α = 0.92). Convergent validity analyses demonstrated further support for the use of the 23-item 1-factor solution over the original PPUS factor structure. CONCLUSION These results demonstrate the preliminary clinical and research utility of the PPUS with caregivers of children with DSD presenting with ambiguous genitalia. The PPUS may benefit from further refinement through qualitative research and item adaptation to capture uncertainties unique to DSD presenting with ambiguous genitalia. In addition, future research should replicate the proposed factor structure using confirmatory factor analysis with a separate, larger sample of caregivers of children with DSD to confirm the factor structure.
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Affiliation(s)
- Nathan L Basile
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
| | - Taylor M Dattilo
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
| | - Alexandra M DeLone
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
| | - Jacob D Kraft
- Department of Psychiatry, University of Michigan, USA
| | - Clayton S Edwards
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, USA
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, USA
| | - Dix P Poppas
- Institute for Pediatric Urology, Komansky Children’s Hospital, New York Presbyterian Hospital-Weill Cornell Medicine, USA
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, USA
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Growing up with clitoromegaly: experiences of North American women with congenital adrenal hyperplasia. J Pediatr Urol 2022; 18:775-783. [PMID: 35752554 DOI: 10.1016/j.jpurol.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/25/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION To describe experiences of clitoromegaly in women with congenital adrenal hyperplasia (CAH). METHODS CAH females (46XX, ≥16 years old) from the United States and Canada were eligible for a cross-sectional online survey (2019-2020) if reporting clitoromegaly (life-long: "growing up with a larger than average clitoris," secondary: "clitoris grew over weeks or months"). A multidisciplinary team and women with CAH drafted questions assessing net effects of clitoromegaly on 10 activities and 10 life domains. Fisher's exact test was used to compare net effect (positive-negative) vs. no effect (Bonferroni p = 0.05/10 = 0.005). RESULTS Of 97 women with CAH enrolled, 53 women (55%, median age: 36 years, advocacy group recruitment: 81%) reported recognizing clitoromegaly at median 11-13 years old, with 21% identifying it in adulthood. There was no difference in self-reported timing or clitoral shape between life-long or secondary clitoromegaly (p ≥ 0.06). There were no net positive effects of clitoromegaly. Rather, clitoromegaly had net negative effects on 7/10 activities (p ≤ 0.003) and no net effect (neutral) on 3 (Table). Women were less likely to wear tight clothing, change clothes in public locker rooms and play group sports. Women reported net negative effects for most romantic activities (dating, any sexual activity, pain-free sexual activity, having a partner see their genitalia, p=<0.003), but did not report a net effect on pleasurable sexual activity (p = 0.12). Clitoromegaly had net negative effects in 9/10 life domains (p < 0.001) and neutral on job self-perception (p = 0.25). Few women reported any positive impact (2-6%). However, 49-59% of women experienced poor self-esteem, anxiety, gender self-perception and body image, while 36% felt "down or depressed." Also, 21-23% experienced negative self-perception as friends and parents, 42-47% reported negative effects on plans for romantic and sexual relationships. Responses did not differ with advocacy group membership (p ≥ 0.02). DISCUSSION Our findings support qualitative and case series evidence that clitoromegaly has a negative psychological outcome on women with CAH. Clitoromegaly may add to the burden of living with a chronic endocrine disease. Women with positive and negative experiences had the same opportunity to participate. Since we could not assess objective clitoral size, baseline virilization and exact nature of any childhood clitoral procedures, these data cannot be used to estimate the impact of specific clitoral size or effectiveness of early clitoral treatments. CONCLUSIONS Clitoromegaly appears to be common among women with CAH. While experiences of clitoromegaly vary between women, the overall experience is negative in multiple social, romantic, and emotional activities and domains.
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Kremen J, Harris RM, Aston CE, Perez M, Austin PF, Baskin L, Cheng EY, Fried A, Kolon T, Kropp B, Lakshmanan Y, Nokoff NJ, Palmer B, Paradis A, Poppas D, Reyes KJS, Wolfe-Christensen C, Diamond DA, Tishelman AC, Mullins LL, Wisniewski AB, Chan YM. Exploring Factors Associated with Decisions about Feminizing Genitoplasty in Differences of Sex Development. J Pediatr Adolesc Gynecol 2022; 35:638-646. [PMID: 35948206 PMCID: PMC9701156 DOI: 10.1016/j.jpag.2022.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/24/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE Infants with genital development considered atypical for assigned female sex may undergo feminizing genitoplasty (clitoroplasty and/or vaginoplasty) in early life. We sought to identify factors associated with parent/caregiver decisions regarding genitoplasty for their children with genital virilization. DESIGN Longitudinal, observational study SETTING: Twelve pediatric centers in the United States with multidisciplinary differences/disorders of sex development clinics, 2015-2020 PARTICIPANTS: Children under 2 years old with genital appearance atypical for female sex of rearing and their parents/caregivers INTERVENTIONS/OUTCOME MEASURES: Data on the child's diagnosis and anatomic characteristics before surgery were extracted from the medical record. Parents/caregivers completed questionnaires on psychosocial distress, experience of uncertainty, cosmetic appearance of their child's genitalia, and demographic characteristics. Urologists rated cosmetic appearance. For 58 patients from the study cohort with genital virilization being raised as girls or gender-neutral, we compared these data across 3 groups based on the child's subsequent surgical intervention: (i) no surgery (n = 5), (ii) vaginoplasty without clitoroplasty (V-only) (n = 15), and (iii) vaginoplasty and clitoroplasty (V+C) (n = 38). RESULTS Fathers' and urologists' ratings of genital appearance were more favorable in the no-surgery group than in the V-only and V+C groups. Clitorophallic length was greater in the V+C group compared with the V-only group, with substantial overlap between groups. Mothers' depressive and anxious symptoms were lower in the no-surgery group compared with the V-only and V+C groups. CONCLUSIONS Surgical decisions were associated with fathers' and urologists' ratings of genital appearance, the child's anatomic characteristics, and mothers' depressive and anxious symptoms. Further research on surgical decision-making is needed to inform counseling practices.
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Affiliation(s)
- Jessica Kremen
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Rebecca M Harris
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Paul F Austin
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Laurence Baskin
- University of California San Francisco Medical Center, UCSF School of Medicine, San Francisco, California
| | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Allyson Fried
- John R. Oishei Children's Hospital, Buffalo, New York
| | - Thomas Kolon
- Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley Kropp
- Oklahoma State University, Stillwater, Oklahoma; OKC Kids, Oklahoma City, Oklahoma
| | - Yegappan Lakshmanan
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
| | - Natalie J Nokoff
- Childrens Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Blake Palmer
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - Alethea Paradis
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Dix Poppas
- New York Presbyterian Hospital, Weill Cornell Medical College, New York City, New York
| | - Kristy J Scott Reyes
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - Cortney Wolfe-Christensen
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - David A Diamond
- Golisano Children's Hospital, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Amy C Tishelman
- Boston College, Morrissey College of Arts and Sciences, Boston, Massachusetts
| | | | - Amy B Wisniewski
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Yee-Ming Chan
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Man E, Mushtaq I, Barnicoat A, Carmichael P, Hughes CR, Davies K, Aitkenhead H, Amin R, Buchanan CR, Cherian A, Costa NJ, Creighton SM, Duffy PG, Hewson E, Hindmarsh PC, Monzani LC, Peters CJ, Ransley PG, Smeulders N, Spoudeas HA, Wood D, Hughes IA, Katugampola H, Brain CE, Dattani MT, Achermann JC. A Single-Center, Observational Study of 607 Children and Young People Presenting With Differences of Sex Development (DSD). J Endocr Soc 2022; 7:bvac165. [DOI: 10.1210/jendso/bvac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Indexed: 11/22/2022] Open
Abstract
Abstract
Context
Differences of sex development (DSD) represent a wide range of conditions presenting at different ages to various health professionals. Establishing a diagnosis, supporting the family, and developing a management plan are important.
Objective
We aimed to better understand the presentation and prevalence of pediatric DSD.
Methods
A retrospective, observational cohort study was undertaken in a single tertiary pediatric center of all children and young people (CYP) referred to a DSD multidisciplinary team over 25 years (1995-2019). In total, 607 CYP (520 regional referrals) were included. Data were analyzed for diagnosis, sex-assignment, age and mode of presentation, additional phenotypic features, mortality, and approximate point prevalence.
Results
Among the 3 major DSD categories, sex chromosome DSD was diagnosed in 11.2% (68/607) (most commonly 45,X/46,XY mosaicism), 46,XY DSD in 61.1% (371/607) (multiple diagnoses often with associated features), while 46,XX DSD occurred in 27.7% (168/607) (often 21-hydroxylase deficiency). Most children (80.1%) presented as neonates, usually with atypical genitalia, adrenal insufficiency, undescended testes or hernias. Those presenting later had diverse features. Rarely, the diagnosis was made antenatally (3.8%, n = 23) or following incidental karyotyping/family history (n = 14). Mortality was surprisingly high in 46,XY children, usually due to complex associated features (46,XY girls, 8.3%; 46,XY boys, 2.7%). The approximate point prevalence of neonatal referrals for investigation of DSD was 1 in 6347 births, and 1 in 5101 overall throughout childhood.
Conclusion
DSD represent a diverse range of conditions that can present at different ages. Pathways for expert diagnosis and management are important to optimize care.
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Affiliation(s)
- Elim Man
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London , London WC1N 1EH , UK
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
- Department of Paediatrics & Adolescent Medicine, Hong Kong Children's Hospital , Hong Kong SAR , People’s Republic of China
| | - Imran Mushtaq
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
| | - Angela Barnicoat
- Department of Clinical Genetics, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Polly Carmichael
- Department of Clinical Psychology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
- Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust , London NW3 5BA , UK
| | - Claire R Hughes
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London , London EC1M 6BQ , UK
| | - Kate Davies
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
- Institute of Health and Social Care, London South Bank University , London SE1 0AA , UK
| | - Helen Aitkenhead
- Department of Chemical Pathology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Rakesh Amin
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Charles R Buchanan
- Department of Child Health, King's College Hospital NHS Foundation Trust , London SE5 9RS , UK
| | - Abraham Cherian
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
| | - Nikola J Costa
- Department of Chemical Pathology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Sarah M Creighton
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust , London NW1 2BU , UK
| | - Patrick G Duffy
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
| | - Emma Hewson
- Department of Clinical Psychology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Peter C Hindmarsh
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
- Department of Paediatrics, University College London Hospitals NHS Foundation Trust , London NW1 2BU , UK
| | - Louisa C Monzani
- Department of Clinical Psychology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Catherine J Peters
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Philip G Ransley
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
| | - Naima Smeulders
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
| | - Helen A Spoudeas
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London , London WC1N 1EH , UK
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Dan Wood
- Department of Urology, Great Ormond Street Hospital for Children , London WC1N 3JH , UK
- Department of Urology, University College London Hospitals NHS Foundation Trust , London NW1 2BU , UK
- Department of Urology, Children's Hospital Colorado and University of Colorado , Aurora, Colorado 80045 , USA
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge , Cambridge CB2 0QQ , UK
| | - Harshini Katugampola
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Caroline E Brain
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - Mehul T Dattani
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London , London WC1N 1EH , UK
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
| | - John C Achermann
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London , London WC1N 1EH , UK
- Department of Endocrinology, Great Ormond Street Hospital NHS Foundation Trust , London WC1N 3JH , UK
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De Clercq E, Starke G, Rost M. "Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:50. [PMID: 36282442 PMCID: PMC9596528 DOI: 10.1007/s40656-022-00533-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.
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Affiliation(s)
- Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- Institute of Biomedical Ethics and History of Medicine, University of Zürich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Georg Starke
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- College of Humanities, École Polytechnique Fédérale de Lausanne, Rte Cantonale, 1015 Lausanne, Switzerland
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
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Traino KA, Baudino MN, Kraft JD, Basile NL, Dattilo TM, Davis MP, Buchanan C, Cheng EY, Poppas DP, Wisniewski AB, Mullins LL. Factor Analysis of the Stigma Scale-Parent Version in Pediatric Disorders/Differences of Sex Development. STIGMA AND HEALTH 2021; 6:390-396. [PMID: 35497259 PMCID: PMC9053364 DOI: 10.1037/sah0000346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Stigma is a salient experience for both caregivers/parents and individuals with Disorders/Differences of Sex Development (DSD) as evidenced through qualitative and preliminary quantitative reports. However, few validated measures of associative stigma (i.e., vicarious stigma experienced through close association with someone who is socially stigmatized) for parents of children with DSD exist. The present study aims to (1) determine the factor structure of the adapted Stigma Scale - Parent, and (2) examine convergent validity of the factor structure with measures of parent psychosocial adjustment. Confirmatory factor analytic results revealed two factors: a parent-focused factor and a child-focused factor. The parent-focused factor demonstrated convergent validity with parent adjustment measures, but the child-focused factor did not. Together, these results indicate that parent-focused and child-focused stigma are distinct factors, with parent-focused associative stigma being related to parent adjustment following DSD diagnosis. Future research should further refine this measure to determine predictive validity and clinical value.
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Affiliation(s)
| | | | - Jacob D. Kraft
- Psychology Department, Oklahoma State University, Stillwater, OK
| | - Nathan L. Basile
- Psychology Department, Oklahoma State University, Stillwater, OK
| | | | - Morgan P. Davis
- Psychology Department, Oklahoma State University, Stillwater, OK
| | - Cindy Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO
| | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL
| | - Dix P. Poppas
- Phyllis & David Komansky Center for Children’s Health of New York Presbyterian Hospital Weill Cornell Medical Center
| | | | - Larry L. Mullins
- Psychology Department, Oklahoma State University, Stillwater, OK
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8
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Long CJ, Van Batavia J, Wisniewski AB, Aston CE, Baskin L, Cheng EY, Lakshmanan Y, Meyer T, Kropp B, Palmer B, Nokoff NJ, Paradis A, VanderBrink B, Scott Reyes KJ, Yerkes E, Poppas DP, Mullins LL, Kolon TF. Post-operative complications following masculinizing genitoplasty in moderate to severe genital atypia: results from a multicenter, observational prospective cohort study. J Pediatr Urol 2021; 17:379-386. [PMID: 33726972 PMCID: PMC8713352 DOI: 10.1016/j.jpurol.2021.02.006] [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: 12/04/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. A phenotype of severe genital atypia in patients raised as male is a relatively rare occurrence and standards for management are lacking. Decision making for early surgical planning in these rare cases includes, but is not limited to, degree of atypia, location of testes, and presence of Mϋllerian remnants. In this study we describe surgical approaches and short-term outcomes for masculinizing genitoplasty in moderate to severe genital atypia in young patients raised male, for whom parents opted for early surgery. METHODS This NIH-sponsored study is an ongoing, observational, multicenter investigation assessing medical, surgical and psychological outcomes in children and their parents affected by atypical genitalia due to DSD. Participants were prospectively enrolled from 12 children's hospitals across the United States that specialize in DSD care. Criteria for child enrollment were a Quigley score of 3-6 in those with a 46, XY or 45,X/46, XY chromosome complement, age <3 years with no previous genitoplasty; patients were included independent of whether genitoplasty was performed. Cosmesis was graded according to a 4-point Likert scale and complications per the Clavian-Dindo classification. RESULTS Of the 31 participants, 30 underwent hypospadias repair and 1 patient did not undergo a genitoplasty procedure. The majority of participants (22) received a staged hypospadias repair. Seventeen complications were identified in 12 of the 31 children (41%) at 12 months of follow up. Glans dehiscence and urethrocutaneous fistula were the most common complications. Orchiopexy was performed in 14 (44%) and streak gonads were removed in 4 (13%) participants. Both parents and surgeons reported improved cosmesis after surgery when compared to baseline. CONCLUSION Genitoplasty was chosen by parents for the majority of children eligible for study. No single surgical approach for masculinizing moderate to severe genital ambiguity in young patients with 46, XY or 45,X/46, XY DSD was adopted by all surgeons. Complications occurred in 41% of those who underwent genitoplasty for severe hypospadias. Overall, appearance of the genitals, as determined by parents and surgeons, improved following genitoplasty. Outcomes of early genitoplasty are needed to guide families when making decisions about such procedures for their young children.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dix P Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, USA.
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Roberts CM, Sharkey CM, Bakula DM, Perez MN, Delozier AJ, Austin PF, Baskin LS, Chan YM, Cheng EY, Diamond DA, Fried AJ, Kropp B, Lakshmanan Y, Meyer SZ, Meyer T, Nokoff NJ, Palmer BW, Paradis A, Reyes KJS, Tishelman A, Williot P, Wolfe-Christensen C, Yerkes EB, Aston C, Wisniewski AB, Mullins LL. Illness Uncertainty Longitudinally Predicts Distress Among Caregivers of Children Born With DSD. J Pediatr Psychol 2021; 45:1053-1062. [PMID: 32929478 DOI: 10.1093/jpepsy/jsaa069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE A subset of parents of children with disorders/differences of sex development (DSD) including ambiguous genitalia experience clinically elevated levels of anxious and depressive symptoms. Research indicates that uncertainty about their child's DSD is associated with parent psychosocial distress; however, previous studies have been cross-sectional or correlational in nature. The current study is the first to examine the longitudinal trajectory of the relationship between caregiver-perceived uncertainty about their child's DSD and caregiver anxious and depressive symptoms across the first 12 months following genital surgery in young children, or if surgery was not performed, the first 12 months following study entry. METHODS One hundred and thirteen caregivers (Mage = 32.12; 57.5% mothers; 72.6% Caucasian) of children (N = 70; Mage = 9.81 months; 65.7% female) with DSD were recruited from 12 DSD specialty clinics in the United States. Caregivers completed psychosocial measures at baseline, 6 and 12 months following genitoplasty, or study entry if parents elected not to have surgery for their child. RESULTS Caregiver illness uncertainty and both anxious and depressive symptoms were highest at baseline and decreased over time (ps < .05). Caregiver illness uncertainty predicted symptoms of anxious and depressive symptoms across all time points (ps < .05). CONCLUSIONS Caregivers' perceptions of uncertainty about their child's DSD are highest soon after diagnosis, and uncertainty continues to predict both anxious and depressive symptoms across time. Thus, the initial diagnostic period is a critical time for psychological assessment and intervention, with parent illness uncertainty being an important clinical target.
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Affiliation(s)
- Caroline M Roberts
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
| | - Christina M Sharkey
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
| | - Dana M Bakula
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
| | - Megan N Perez
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
| | | | | | - Laurence S Baskin
- Department of Urology, University of California San Francisco Medical Center
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | - David A Diamond
- Department of Urology, Boston Children's Hospital, Harvard Medical School
| | - Allyson J Fried
- Pediatric Urology of Western New York, John R. Oishei Children's Hospital
| | | | | | - Sabrina Z Meyer
- Pediatric Urology of Western New York, John R. Oishei Children's Hospital
| | - Theresa Meyer
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Natalie J Nokoff
- Department of Endocrinology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus
| | - Blake W Palmer
- Department of Pediatric Urology, Cook Children's Medical Center
| | | | | | - Amy Tishelman
- Department of Urology, Boston Children's Hospital, Harvard Medical School.,Department of Psychiatry, Boston Children's Hospital, Harvard Medical School
| | - Pierre Williot
- Pediatric Urology of Western New York, John R. Oishei Children's Hospital
| | | | - Elizabeth B Yerkes
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Christopher Aston
- Department of Pediatrics, University of Oklahoma Health Sciences Center
| | - Amy B Wisniewski
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
| | - Larry L Mullins
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University
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10
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Baskin A, Wisniewski AB, Aston CE, Austin P, Chan YM, Cheng EY, Diamond DA, Fried A, Kolon T, Lakshmanan Y, Williot P, Meyer S, Meyer T, Kropp B, Nokoff N, Palmer B, Paradis A, Poppas D, VanderBrink B, Scott Reyes KJ, Tishelman A, Wolfe-Christensen C, Yerkes E, Mullins LL, Baskin L. Post-operative complications following feminizing genitoplasty in moderate to severe genital atypia: Results from a multicenter, observational prospective cohort study. J Pediatr Urol 2020; 16:568-575. [PMID: 32624410 PMCID: PMC7735165 DOI: 10.1016/j.jpurol.2020.05.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 12/14/2022]
Abstract
Disorders/differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. While there remains controversy around the traditionally binary concept of sex, most patients with DSD are reared either male or female depending on their genetic sex, gonadal sex, genital phenotype and status of their internal genital tract. This study uses prospective data from 12 institutions across the United States that specialize in DSD care. We focused on patients raised female. Eligible patients had moderate to severe genital atypia (defined as Prader score >2), were ≤2 years of age at entry, and had no prior genitoplasty. The aim of this study is to describe early post operative complications for young patients undergoing modern approaches to feminizing genitoplasty. Of the 91 participants in the cohort, 57 (62%) were reared female. The majority had congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (n = 52), 1 had ovo-testicular syndrome, 2 had mixed gonadal dysgenesis and 2 had partial androgen insensitivity syndrome (PAIS). Of the 50 participants who received early genitoplasty, 43 (86%) had follow-up at 6-12 months post-surgery. Thirty-two participants (64%) received a clitoroplasty, 31 (62%) partial urogenital mobilization and 4 (8%) total urogenital sinus mobilization. Eighteen percent (9/50) experienced post-surgical complications with 7 (14%) being rated as Clavien-Dindo grade III. Both parents and surgeons reported improved satisfaction with genital appearance of participants following surgery compared to baseline. This information on post-operative complications associated with contemporary approaches to feminizing genitoplasty performed in young children will help guide families when making decisions about whether or not to proceed with surgery for female patients with moderate to severe genital atypia.
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Affiliation(s)
- Avi Baskin
- University of California San Francisco Medical Center, United States.
| | | | | | - Paul Austin
- Texas Children's Hospital and Baylor College of Medicine, United States.
| | | | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, United States.
| | | | | | - Thomas Kolon
- Children's Hospital of Philadelphia, United States.
| | | | | | | | - Theresa Meyer
- Lurie Children's Hospital of Chicago, United States.
| | | | | | | | | | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, United States.
| | | | | | | | | | | | | | - Laurence Baskin
- University of California San Francisco Medical Center, United States.
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11
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Perez MN, Delozier AM, Aston CE, Austin P, Baskin L, Chan YM, Cheng EY, Diamond DA, Fried A, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Nokoff N, Palmer B, Paradis A, Poppas D, Scott Reyes KJ, Swartz JM, Tishelman A, Wisniewski AB, Wolfe-Christensen C, Yerkes E, Mullins LL. Predictors of Psychosocial Distress in Parents of Young Children with Disorders of Sex Development. J Urol 2019; 202:1046-1051. [PMID: 31268850 DOI: 10.1097/ju.0000000000000424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated demographic, financial and support predictors of distress for parents of young children with disorders of sex development including atypical genital development, and characterized early parental experiences. This work extends our previous findings to identify those parents at risk for distress. MATERIALS AND METHODS Participants included mothers (76) and fathers (63) of a child (78) diagnosed with disorders of sex development characterized by moderate to severe genital atypia. Parents completed a demographic questionnaire, measures of anxious and depressive symptoms, quality of life, illness uncertainty and posttraumatic stress symptoms, and rated their satisfaction with the appearance of their child's genitalia. RESULTS Depressive and posttraumatic stress symptoms of caregivers were comparable to standardized norms while levels of anxious symptoms were below norms. A subset of parents reported clinically elevated symptoms. Overall 26% of parents reported anxious symptoms, 24% reported depressive symptoms and 17% reported posttraumatic stress symptoms. Levels of illness uncertainty were lower than those of parents of children with other chronic illnesses. Differences by parent sex emerged, with mothers reporting greater distress. Lower income, increased medical care and travel expenses, and having no other children were related to increased psychosocial distress. CONCLUSIONS Early psychosocial screening is recommended for parents of children with disorders of sex development. Clinicians should be aware that financial burden and lack of previous parenting experience are risk factors for distress.
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Affiliation(s)
| | | | | | - Paul Austin
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Laurence Baskin
- University of California San Francisco Medical Center, San Francisco, California
| | | | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Allyson Fried
- John R. Oishei Children's Hospital, Buffalo, New York
| | | | - Thomas Kolon
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Sabrina Meyer
- John R. Oishei Children's Hospital, Buffalo, New York
| | - Theresa Meyer
- Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Blake Palmer
- Cook Children's Medical Center, Ft. Worth, Texas
| | | | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
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