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Gramc M, Monro S, Stephenson J, Streuli J. Psychosocial Support for Parents, Infants, Children, and Adolescents with Variations of Sex Characteristics: Results from a Pan-European Survey. Behav Sci (Basel) 2024; 14:832. [PMID: 39336047 PMCID: PMC11429105 DOI: 10.3390/bs14090832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 09/12/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
Early psychosocial support for parents/legal guardians who have children with variations of sex characteristics (VSCs) is crucial in helping avoid potentially harmful medical procedures. Psychosocial support, including peer support, can help parents/legal guardians choose the best care path for their child, and it remains important throughout childhood. However, there is a lack of data on the provision of psychosocial support for families with a child who has VSCs. We sought knowledge about the timing and types of psychosocial support, and the level of implementation of psychosocial support amongst health and psychosocial care professionals and peer supporters. A survey was conducted using a purposive sample of healthcare professionals and members of peer support groups across Europe. A total of 301 responses were received and analysed using descriptive and inferential methods. The survey results showed that psychosocial support primarily addresses diagnostic procedures, medical treatment, and medical interventions. Whilst the majority of healthcare professionals aspired to have psychosocial support provided at the point where a diagnosis of VSCs was suspected, this was only reported as current practice by a minority of respondents. Overall, the survey indicates that there is a need for greater implementation of psychosocial support, and more collaboration between healthcare professionals and peer support groups in caring for children with VSCs and their families.
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Affiliation(s)
- Martin Gramc
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, 8006 Zürich, Switzerland; (M.G.); (J.S.)
| | - Surya Monro
- Centre for Gender and Africa Studies, Faculty of the Humanities, University of the Free State South Africa, Bloemfontein 9301, South Africa
- Department of Criminology, Sociology, and Social Policy, School of Social Sciences and Humanities, Loughborough Campus, Loughborough University UK, Loughborough LE11 3TU, UK
| | - John Stephenson
- Department of Allied Health Professions, Sport and Exercise, School of Human and Health Sciences, Huddersfield University, Queensgate, Huddersfield HD1 3DH, UK;
| | - Jürg Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, 8006 Zürich, Switzerland; (M.G.); (J.S.)
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Khorashad BS, Gardner M, Lee PA, Kogan BA, Sandberg DE. DSD-related attitudes and beliefs held by pediatric endocrinologists and urologists: Insights from the North American disorders/differences of sex development (DSD) clinician survey. J Pediatr Urol 2024:S1477-5131(24)00460-1. [PMID: 39353745 DOI: 10.1016/j.jpurol.2024.09.006] [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: 06/04/2024] [Revised: 08/30/2024] [Accepted: 09/08/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Disorders/Differences of Sex Development (DSD) encompass congenital conditions with atypical development of chromosomal, gonadal, or anatomical sex. Due to the rarity and complexity of these conditions, strong evidence for clinical practices is scarce, leading to controversies in management. OBJECTIVE This study, part of a broader project, examines changes over time in the attitudes and beliefs of DSD healthcare providers, focusing on factors contributing to patients' life satisfaction and the influence of medical specialty, gender, and age. METHODS Participants included active members of the Pediatric Endocrine Society (PES) and the Societies for Pediatric Urology (SPU) at three time points: 2003-2004 (T1), 2010-2011 (T2), and 2020 (T3). A survey covering predictors of patient life satisfaction, attitudes and beliefs regarding DSD care and outcomes, and participant characteristics was administered. Data were analyzed using descriptive statistics and Generalized Estimating Equations (GEE). RESULTS Demographics: Participation rates were 56% (PES) and 64.7% (SPU) at T1, 41.1% (PES) and 52.3% (SPU) at T2, and 25.6% (PES) and 51.2% (SPU) at T3. Most participants were male (T1: 70.6%, T2: 61.7%, T3: 70.6%). Factors Affecting Life Satisfaction: Both endocrinologists and urologists ranked "gender identity consistent with assigned sex" as most important. Over time, the endorsement of some factors, such as performing genital surgery at Centers of Excellence, increased, while others, like the influence of prenatal androgen exposure determining gender identity, varied by specialty and gender. Attitudes and Beliefs: Across 18 statements, responses indicated three clusters with strong agreement, moderate agreement, and strong disagreement. Statements on the importance of family background and avoiding gender discordance were consistently endorsed, while those on delaying hypospadias repair until consent were least endorsed. DISCUSSION The study highlights variability in beliefs about DSD management over time, influenced by specialty, gender, and age. Despite consensus on some care principles, discrepancies remain, particularly regarding the impact of prenatal androgens and the timing of surgical interventions. These findings underscore the need for regular interdisciplinary communication to align clinical practices with evidence-based guidelines and address subjective beliefs. CONCLUSION The survey illustrates evolving perspectives among DSD healthcare providers, emphasizing the need for continued dialogue and education to bridge gaps between clinical evidence and practice. Collaborative efforts, such as the international I-DSD and the U.S. DSD Translational Research Network, are crucial for advancing patient-centered care in this field.
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Affiliation(s)
- Behzad Sorouri Khorashad
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College, 23 Hackett Blvd Albany, NY, 12208, USA
| | - David E Sandberg
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA; Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA.
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Traino KA, Ciciolla LM, Perez MN, Chaney JM, Welch G, Baskin LS, Buchanan CL, Chan YM, Cheng EY, Coplen DE, Wisniewski AB, Mullins LL. Trajectories of illness uncertainty among parents of children with atypical genital appearance due to differences of sex development. J Pediatr Psychol 2024; 49:559-570. [PMID: 38857449 PMCID: PMC11335143 DOI: 10.1093/jpepsy/jsae043] [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: 10/22/2023] [Revised: 04/14/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE The present study aimed to identify distinct trajectories of parental illness uncertainty among parents of children born with atypical genital appearance due to a difference of sex development over the first year following diagnosis. It was hypothesized that four trajectory classes would emerge, including "low stable," "high stable," "decreasing," and "increasing" classes, and that select demographic, familial, and medical factors would predict these classes. METHODS Participants included 56 mothers and 43 fathers of 57 children born with moderate to severe genital atypia. Participants were recruited from eleven specialty clinics across the U.S. Growth mixture modeling (GMM) approaches, controlling for parent dyad clustering, were conducted to examine classes of parental illness uncertainty ratings over time. RESULTS A three-class GMM was identified as the best-fitting model. The three classes were interpreted as "moderate stable" (56.8%), "low stable" (33.0%), and "declining" (10.3%). Findings suggest possible diagnostic differences across trajectories. CONCLUSIONS Findings highlight the nature of parents' perceptions of ambiguity and uncertainty about their child's diagnosis and treatment the year following their child's birth/diagnosis. Future research is needed to better understand how these trajectories might shift over the course of the child's development. Results support the development of tailored, evidence-based interventions to address coping with uncertainty among families raising a child with chronic health needs.
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Affiliation(s)
- Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Lucia M Ciciolla
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Megan N Perez
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - John M Chaney
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Ginger Welch
- Department of Human Development and Family Sciences, Oklahoma State University, Stillwater, OK, United States
| | - Laurence S Baskin
- Department of Urology, University of California San Francisco Medical Center, San Francisco, CA, United States
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Yee-Ming Chan
- Division of Endocrinology, and Harvard Medical School, Boston Children’s Hospital, Boston, MA, United States
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Douglas E Coplen
- Division of Urologic Surgery, St. Louis Children’s Hospital, St Louis, MO, United States
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
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Crerand CE, Shehata A, Umbaugh H, Kapa HM, Hansen-Moore J, Nahata L, Buchanan C, Chen D, Rausch J, Udaipuria S, Jayanthi VR, Chan YM, Pratt KJ, Buschur E, Indyk J, Tishelman AC. Body image and psychosocial outcomes in youth and young adults with differences of sex development: a multi-method study. J Pediatr Psychol 2024; 49:512-523. [PMID: 38867313 DOI: 10.1093/jpepsy/jsae041] [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: 11/22/2023] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/14/2024] Open
Abstract
OBJECTIVE Differences of sex development (DSD) can affect the physical health, appearance, and psychosocial functioning of affected individuals, but little is known about how subjective appearance perceptions (body image) impact psychosocial outcomes. This study evaluated body image and its associations with psychosocial outcomes including quality of life, resilience, and psychosocial adjustment. METHODS This cross-sectional, multi-method study assessed body image and psychosocial outcomes including quality of life, adjustment, and resilience in 97 youth and young adults with DSD (mean age = 17 ± 3.7 years; 56% assigned female in infancy) using psychometrically sound instruments. A subsample (n = 40) completed qualitative interviews. RESULTS Quantitative results indicated that overall, participants were satisfied with their physical appearance, although less so with their primary sex characteristics. Body image dissatisfaction was associated with poorer psychosocial adjustment, quality of life, and resilience. Qualitatively, youth and young adults reported a variety of perceptions, both positive and negative, related to their body image and the impact of living with a DSD condition. Themes identified included appearance management; effects of DSD on body image; diagnostic factors and features; attitudes about diagnosis; and treatment. CONCLUSIONS Body image is significantly associated with psychosocial outcomes in youth and young adults with DSD, with qualitative findings highlighting both positive and negative body image experiences. Results have implications for clinical care including screening for appearance concerns, normalization of appearance variations, and intervention development to better support healthy body image and psychosocial functioning in youth and young adults with DSD.
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Affiliation(s)
- Canice E Crerand
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Ayah Shehata
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Hailey Umbaugh
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Hillary M Kapa
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jennifer Hansen-Moore
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Leena Nahata
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Cindy Buchanan
- Department of Psychiatry, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Diane Chen
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Departments of Psychiatry and Behavioral Sciences, and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph Rausch
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Shivika Udaipuria
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Venkata R Jayanthi
- Department of Urology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Yee-Ming Chan
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Keeley J Pratt
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH, United States
| | - Elizabeth Buschur
- Department of Endocrinology, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, United States
| | - Justin Indyk
- Department of Endocrinology, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, United States
| | - Amy C Tishelman
- Department of Psychology and Neuroscience, Boston College, Boston, MA, United States
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Alderson J, Thornton M, Skae M, Jones J, Nicoll N, Harcourt D, Woodward M, Crowne EC. Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention. J Sex Med 2024; 21:361-366. [PMID: 38481013 DOI: 10.1093/jsxmed/qdae024] [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: 07/13/2023] [Revised: 01/20/2024] [Accepted: 02/04/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication. AIM We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH. METHODS Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children). OUTCOMES Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups. RESULTS For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function. CLINICAL IMPLICATIONS Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions. STRENGTHS AND LIMITATIONS This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care. CONCLUSION Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.
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Affiliation(s)
- Julie Alderson
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, United Kingdom
| | - Maia Thornton
- University of the West of England, Stoke Gifford, Bristol BS16 1QY, United Kingdom
| | - Mars Skae
- Manchester University NHS Foundation Trust, Cobbett House Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Julie Jones
- Manchester University NHS Foundation Trust, Cobbett House Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Nicky Nicoll
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, United Kingdom
| | - Diana Harcourt
- University of the West of England, Stoke Gifford, Bristol BS16 1QY, United Kingdom
| | - Mark Woodward
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, United Kingdom
| | - Elizabeth C Crowne
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 3NU, United Kingdom
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6
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Crocetti D, Berry A, Monro S. Navigating the complexities of adult healthcare for individuals with variations of sex characteristics: from paediatric emergencies to a sense of abandonment. CULTURE, HEALTH & SEXUALITY 2024; 26:332-345. [PMID: 37199261 DOI: 10.1080/13691058.2023.2208194] [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: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
Intersex people and those with variations of sex characteristics face significant health and social issues. This paper analyses the complexities of adult healthcare for this diverse population, including the root causes of deficiencies in care provision. Many minors with variations of sex characteristics are subjected to irreversible, non-consensual medical interventions, which can have negative effects on their health and wellbeing as adults. This 'emergency' approach to intersex paediatric healthcare has been challenged since the 1990s, but there is still a lack of understanding about how the paradigm affects adult care. This paper aims to raise awareness of the health challenges faced by adults with variations of sex characteristics. It identifies themes related to the challenges associated with accessing appropriate adult care, including the repercussions of childhood treatment, the lack of transitional services and psychological support, the limited general medical knowledge about variations of sex characteristics, and the reluctance to access services due to fear of stigma or past medical trauma. The paper indicates the need for more attention to intersex people's health needs as adults, moving away from attempts to 'fix' them as minors towards approaches which consider and provide for their diverse healthcare needs in a broader temporal context.
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Affiliation(s)
- Daniela Crocetti
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
- subsequently Independent Researcher, Intersexesiste NGO, Bologna, Italy
| | - Adeline Berry
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Surya Monro
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
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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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Gardner M, Brinkman WB, Carley M, Liang N, Lightfoot S, Pinkelman K, Speiser PW, Schafer-Kalkhoff T, Suorsa-Johnson KI, VanderBrink B, Weidler EM, Wisniewski J, Stacey D, Sandberg DE. Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development. FRONTIERS IN UROLOGY 2023; 3:1089077. [PMID: 37920725 PMCID: PMC10621652 DOI: 10.3389/fruro.2023.1089077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support. Methods 34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted. Results Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information. Discussion Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.
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Affiliation(s)
- Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William B. Brinkman
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noi Liang
- Patient / parent / caregiver stakeholder partners, Denver, CO, USA
| | | | - Kendra Pinkelman
- Patient / parent / caregiver stakeholder partners, Ann Arbor, MI, USA
| | - Phyllis W. Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | | | - Brian VanderBrink
- Division of Urology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ
- Accord Alliance, USA
| | | | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
- Accord Alliance, USA
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Alderson J, Skae M, Crowne EC. Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH). Int J Impot Res 2023; 35:56-60. [PMID: 35672389 DOI: 10.1038/s41443-022-00578-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 11/09/2022]
Abstract
Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.
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Affiliation(s)
- Julie Alderson
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - Mars Skae
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Elizabeth C Crowne
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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10
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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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11
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Alderson J, Hamblin RP, Crowne EC. Psychological Care of Children and Families with Variations or Differences in Sex Development. Horm Res Paediatr 2022; 96:222-227. [PMID: 35390804 DOI: 10.1159/000524517] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 04/01/2022] [Indexed: 11/19/2022] Open
Abstract
Paediatric clinical psychology literature provides applicable evidence for use in specialist health care settings and services. The general approach of psychological care of children and families with paediatric conditions is recognisable as preventative and de-stigmatising, aimed to maximise personal agency with shared responsibility for achieving best outcomes via multi-professional teamwork. Recent commentaries regarding healthcare for children with different sex development (DSD), have noted service-level pitfalls including poor teamwork and underuse of early and integrated psychological intervention. Psychological research regarding the variously termed DSD, Variations in Sex Development (VSD, Variation in Sex Characteristics (VSC), or intersex, has historically centred around the assessment of sex differences, gender identity and the impact of including hormone influences on brain and behaviour. Psychological research in this specialist area has not focussed on the evaluation of specific clinical interventions or psychotherapeutic models but has investigated psychological aspects of multi-professional healthcare provision. There are new goals for psychological care of children with variation or difference in sex development. These require a framework of good communication to enable those receiving care to come to know and articulate their own hopes for treatment and support. Paediatric psychological intervention studies involving larger clinical groups such as diabetes, provide evidence applicable to DSD populations. A risk of stigma is recognised as inherent to some physical interventions within routine paediatric care of people with variations or differences in sex development. Psychological care and intervention should be aimed at minimising these risks via questioning and examining their assumed need. Psychological approaches can provide a foundation for ethical and rights-based multi-professional care of children with variation or difference in sex development.
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12
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Sandberg DE, Gardner M. Differences/Disorders of Sex Development: Medical Conditions at the Intersection of Sex and Gender. Annu Rev Clin Psychol 2022; 18:201-231. [PMID: 35216524 PMCID: PMC10170864 DOI: 10.1146/annurev-clinpsy-081219-101412] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Defined as congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical, differences or disorders of sex development (DSDs) comprise many discrete diagnoses ranging from those associated with few phenotypic differences between affected and unaffected individuals to those where questions arise regarding gender of rearing, gonadal tumor risk, genital surgery, and fertility. Controversies exist in numerous areas including how DSDs are conceptualized, how to refer to the set of conditions and those affected by them, and aspects of clinical management that extend from social media to legislative bodies, courts of law, medicine, clinical practice, and scholarly research in psychology and sociology. In addition to these aspects, this review covers biological and social influences on psychosocial development and adjustment, the psychosocial and psychosexual adaptation of people born with DSDs, and roles for clinical psychologists in the clinical management of DSDs. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
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13
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Maritska Z, Saputro E, Pangestu R, Faulinza E, Sakinah M, Pranandita F, Satopoh F, Ridwan I, Amalia S. Current status of disorders of sexual development in Indonesia. ADVANCES IN HUMAN BIOLOGY 2022. [DOI: 10.4103/aihb.aihb_146_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Miano P, Di Salvo G, Lavaggi M. An undermined therapeutic alliance: A case study. PSYCHODYNAMIC PRACTICE 2021. [DOI: 10.1080/14753634.2021.1972035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Paola Miano
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Italy
| | | | - Massimo Lavaggi
- Associazione Consultorio Transgenere, Torre Del Lago Puccini, Italy
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15
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Kavanaugh GL, Mohnach L, Youngblom J, Kellison JG, Sandberg DE. "Good practices" in pediatric clinical care for disorders/differences of sex development. Endocrine 2021; 73:723-733. [PMID: 34021489 PMCID: PMC8325784 DOI: 10.1007/s12020-021-02748-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/30/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To define, benchmark, and publicize elements of quality care (i.e., "good practices") for pediatric patients with disorders/differences of sex development (DSD). METHODS Principles of quality care were identified by literature review; consensus exists for 11 good practices and adherence was evaluated through online survey of 21 North American clinical sites. RESULTS Strong uptake was observed for many practices, particularly specialty participation (n ≥ 17 of 21 sites for most core specialties); point of contact (n = 18); expertise in gender dysphoria/dissatisfaction (n = 20); and DSD-specific continuing medical education (n = 18). Greater variability was apparent for frequency of peer support referrals (n = 12 universally practiced); standardized questionnaires for routine assessment of psychosocial adaptation (n = 13) and gender development (n = 10); consistently clarifying patient/family values in decision-making (n = 15); genital exam protocols that exclude trainee education as primary reason (n = 15); and internal patient-tracking efforts (n = 5-10 of 20 sites). CONCLUSION This study employed a novel approach to designate DSD good practices and identified areas of consistency and variation in these DSD clinical practices. Good practice benchmarking facilitates quality assessment within and across sites, promotes continuous improvement, and empowers stakeholders in locating and delivering high quality care.
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Affiliation(s)
- Grace L Kavanaugh
- Department of Biology, California State University, Stanislaus, CA, USA
- Accord Alliance, Higley, AZ, USA
| | - Lauren Mohnach
- Fetal Diagnostic and Treatment Center and Differences of Sex Development Clinic, University of Michigan, Ann Arbor, MI, USA
| | - Janey Youngblom
- Department of Biology, California State University, Stanislaus, CA, USA
| | - Joshua G Kellison
- Accord Alliance, Higley, AZ, USA
- Sexual Orientation and Gender Institute of Arizona, Mesa, AZ, USA
| | - David E Sandberg
- Accord Alliance, Higley, AZ, USA.
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA.
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16
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Hansen-Moore JA, Kapa HM, Litteral JL, Nahata L, Indyk JA, Jayanthi VR, Chan YM, Tishelman AC, Crerand CE. Psychosocial Functioning Among Children With and Without Differences of Sex Development. J Pediatr Psychol 2021; 46:69-79. [PMID: 33313877 DOI: 10.1093/jpepsy/jsaa089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess health-related quality of life (HRQoL), psychosocial adjustment, and family functioning of children with differences of sex development (DSD) or cleft lip and/or palate (CL/P). METHODS In this cross-sectional study, parents of children with DSD (n = 67), CL/P (n = 121), and a comparison group of unaffected youth (n = 126) completed standardized measures assessing family functioning and their children's HRQoL and psychosocial adjustment. Medical charts were abstracted for youth with either congenital condition. RESULTS Children with DSD were rated as having significantly lower HRQoL and greater internalizing problems compared to youth with CL/P and unaffected youth. Children in the DSD group were also significantly more likely to fall into the clinical risk categories for total and internalizing problems relative to the CL/P and unaffected groups. Caregivers of children with DSD were significantly more likely to endorse items about child suicidality compared with caregivers in the CL/P and unaffected groups. No significant differences were found between groups for externalizing problems or the expressiveness domain of family functioning; parents of children with DSD reported significantly less family conflict relative to the other groups and greater cohesion relative to the unaffected group. Conclusions Youth with DSD appear to be at greater risk for psychosocial problems relative to children with CL/P and unaffected peers. Results underscore the need for integrated interdisciplinary care and ongoing psychosocial risk monitoring in youth with DSD.
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Affiliation(s)
- Jennifer A Hansen-Moore
- Nationwide Children's Hospital.,Department of Pediatrics, The Ohio State University College of Medicine
| | - Hillary M Kapa
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital
| | - Jennifer L Litteral
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital
| | - Leena Nahata
- Nationwide Children's Hospital.,Department of Pediatrics, The Ohio State University College of Medicine.,Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital
| | - Justin A Indyk
- Nationwide Children's Hospital.,Department of Pediatrics, The Ohio State University College of Medicine
| | - Venkata R Jayanthi
- Nationwide Children's Hospital.,Department of Urology, The Ohio State University College of Medicine
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital.,Department of Pediatrics, Harvard Medical School
| | - Amy C Tishelman
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital.,Department of Psychiatry, Harvard Medical School
| | - Canice E Crerand
- Nationwide Children's Hospital.,Department of Pediatrics, The Ohio State University College of Medicine.,Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital.,Department of Plastic Surgery, The Ohio State University College of Medicine
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17
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Lampalzer U, Briken P, Schweizer K. Psychosocial care and support in the field of intersex/diverse sex development (dsd): counselling experiences, localisation and needed improvements. Int J Impot Res 2021; 33:228-242. [PMID: 33727692 PMCID: PMC7985030 DOI: 10.1038/s41443-021-00422-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
From different sides, there is a call for better psychosocial care and counselling in the field of diverse sex development (dsd). However, studies on the specific demands, deficits and needed improvements regarding those services are rare. This exploratory online study aimed at investigating counselling experiences and the ideas that different groups of participants have concerning the localisation of counselling structures and improving care. Quantitative and qualitative data (N = 630) were analysed within a mixed methods framework. The participants included experts of experience resp. patients with different intersex/dsd conditions (n = 40), parents of children with dsd (n = 27), professional psychosocial counsellors (n = 321) and experts in the field including medical practitioners, psychologists, natural and social scientists as well as others involved, e.g., students or relatives (n = 56). The results show a gap between receiving psychosocial and medical care in the group of adult lived-experience experts, who had received less psychosocial care than medical interventions. The findings also reveal important tasks of psychosocial care. A focus was set on parental experiences. Helpful aspects reported were talking with other parents of children with intersex/dsd, aspects missed were assistance in supporting the individual development of their children. The majority of all participants (58%) held the view that, apart from multidisciplinary competence centres, there also have to be easily accessible counselling services which offer support in everyday life. The participants named increasing quality and quantity as necessary improvements in counselling structures for children and adults with intersex/dsd and their families. Implications are drawn for the specific tasks and target groups of psychosocial care and needed research in intersex healthcare over life span.
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Affiliation(s)
- Ute Lampalzer
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Psychosoziale Versorgung bei Intersex/Varianten der Geschlechtsentwicklung. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-020-00361-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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19
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Bangalore Krishna K, Kogan BA, Ernst MM, Romao RL, Mohsin F, Serrano-Gonzalez M, Quintos JB, Phornphutkul C, Aguiar L, Lee PA. Individualized care for patients with intersex (disorders/differences of sex development): Part 3. J Pediatr Urol 2020; 16:598-605. [PMID: 32605872 DOI: 10.1016/j.jpurol.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment. We recommend an individualized approach by a multidisciplinary team utilizing a range of evolving strategies, including outcome data (or lack thereof) to support families during the decision-making process.
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Affiliation(s)
| | | | - Michelle M Ernst
- University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | | | | | | | | | - Chanika Phornphutkul
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Liza Aguiar
- The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA
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20
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Crocetti D, Arfini EAG, Monro S, Yeadon-Lee T. 'You're basically calling doctors torturers': stakeholder framing issues around naming intersex rights claims as human rights abuses. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:943-958. [PMID: 32133671 DOI: 10.1111/1467-9566.13072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In this article we address activist, patient advocate and medic perspectives on framing intersex, variations of sex characteristics and disorders/differences in sex development medical treatment as human rights abuses. Problematic aspects of intersex medical treatment have increasingly been highlighted in national debates and international human rights bodies. Some intersex activists have framed aspects of intersex medical treatment as human rights abuses since the 1990s. Other stakeholders in shaping medical treatment, such as patient advocates and medical professionals, are not always content with human rights framing, or even the term intersex. In order to address the different perspectives in this arena we provide background on the primary rights claims that have arisen followed by key human rights framing of these claims. We provide a short discussion of activism styles, looking at pan-intersex social movements and variation-specific patient associations as different styles of health social movements. The analysis of stakeholder perspectives on the use of human rights strategy in health areas provides a useful case study for medical sociology and policy in general.
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Affiliation(s)
- Daniela Crocetti
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | | | - Surya Monro
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Tray Yeadon-Lee
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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21
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Lee PA, Fuqua JS, Houk CP, Kogan BA, Mazur T, Caldamone A. Individualized care for patients with intersex (disorders/differences of sex development): part I. J Pediatr Urol 2020; 16:230-237. [PMID: 32249189 DOI: 10.1016/j.jpurol.2020.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022]
Abstract
The care of individuals with disorders/differences of sex development aims to enable affected individuals and their families to have the best quality of life, particularly those born with severe genital ambiguity. Two of the biggest concerns for parents and health professionals are: (1) making a gender assignment and (2) the decisions of whether or not surgery is indicated, and if so, when is best for the patient and parents. These decisions, which can be overwhelming to families, are almost always made in the face of uncertainties. Such decisions must involve the parents, include multidisciplinary contributions, have an underlying principle of full disclosure, and respect familial, philosophical, and cultural values. Assignment as male or female is made with the realization that gender identity cannot be predicted with certainty. Because of the variability among those with the same diagnosis and complexity of phenotype-genotype correlation, the use of algorithms is inappropriate. The goal of this article is to emphasize the need for individualized care to make the best possible decisions for each patient's unique situation.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Hershey, PA 17033, USA.
| | - John S Fuqua
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | | | | | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, John R. Oishei Children's Hospital, Buffalo, NY 14222, USA.
| | - Anthony Caldamone
- Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI 02903, USA.
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22
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Liao LM, Roen K. The role of psychologists in multi-disciplinary teams for intersex/diverse sex development: interviews with British and Swedish clinical specialists. PSYCHOLOGY & SEXUALITY 2019. [DOI: 10.1080/19419899.2019.1689158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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23
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Weidler EM, Baratz A, Muscarella M, Hernandez SJ, van Leeuwen K. A shared decision-making tool for individuals living with complete androgen insensitivity syndrome. Semin Pediatr Surg 2019; 28:150844. [PMID: 31668289 PMCID: PMC7208826 DOI: 10.1016/j.sempedsurg.2019.150844] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Reports exist regarding a gradual approach to the care of patients with differences of sexual development. Each patient and family have different values and styles of learning that have to be taken into account. The goals of care should include education about the condition, counseling of the patient and family, and a complete outlining of treatment options. Motivated by a call from the 2010 Health Reform Law for the use of shared decision-making tools and the emphasis placed on these issues by the DSD Consensus Statement, we sought to develop and implement such tools for the DSD population.1-3 Thus, we developed an organized checklist for providers to share with a patients and families affected by CAIS, beginning with the initial visit. The development of the document enlisted input from physicians, clinical coordinator, advocacy groups and affected individuals. It allows providers to explain the process of care and develop a plan for delivery of that care over multiple visits spanning six months or more. The checklist is divided into five sections: 1) An overview addressing how much information is desired and in what manner the patient prefers to obtain information; 2) A preferred words list so that the patient can choose nomenclature that is most comfortable; 3) A list of topics to review over the course of multiple visits; 4) A list of questions to be answered by the providers or other resources over time, and; 5) A list of concerns to be addressed before surgical intervention is considered. An organized approach to long-term delivery of compassionate care and accurate information can be facilitated for patients with CAIS by the use of a shared decision-making checklist. Documentation of the care delivery process can stimulate referral to peer support and promote fully informed consent for treatment decisions. The use of the checklist should encourage trust in the provider, as well as aid in identifying and addressing stressors for the patient and family. The checklist will be updated and revised as new treatments and advanced technology emerges.
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Affiliation(s)
- Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States
| | - Arlene Baratz
- Androgen Insensitivity Syndrome-Differences of Sex Development Support Group, Duncan, OK, United States,Interact Advocates for Intersex Youth, Sudbury, MA, United States
| | - Miriam Muscarella
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - S. Janett Hernandez
- Division of Pediatric Surgery, Phoenix Children’s Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, United States.
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Abstract
PURPOSE OF REVIEW To provide a framework for the evaluation of ambiguous genitalia. RECENT FINDINGS The most pressing evaluation of ambiguous genitalia is assessment for life-threatening causes such as salt-wasting congenital adrenal hyperplasia (CAH) or syndromes with underlying anomalies such as neurologic or cardiac malformations. A multidisciplinary team, including specialists in Gynecology, Endocrinology, Urology, Genetics, Clinical Psychology/Psychiatry, Radiology, Nursing, Neonatology, and Pediatric Surgery, should be involved. Each patient should be approached in an individualized manner to assign sex of rearing in the most expeditious yet thoughtful means possible.As knowledge on the natural history of sex preference and fertility of individuals with ambiguous genitalia increases, controversy regarding the indication for and timing of genital surgery continues. Considerations include gender identity, future fertility, malignancy risk, infection prevention, and functional anatomy for sexual activity. SUMMARY The evaluation of ambiguous genitalia should involve a multidisciplinary team. A combination of history taking, physical examination, laboratory evaluation, and radiologic assessment can assist with the diagnosis. Care should be taken to emphasize karyotypic sex is not equivalent to gender and to use caution with regards to irreversible medical and surgical therapies which may impact fertility and sexual function and nonconform with future sex identity.
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25
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Harris RM, Chan YM. Ethical issues with early genitoplasty in children with disorders of sex development. Curr Opin Endocrinol Diabetes Obes 2019; 26:49-53. [PMID: 30507698 DOI: 10.1097/med.0000000000000460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Genitoplasty in children with disorders of sex development (DSD) is an ethically complex issue. From a surgical perspective, genitoplasty in early childhood is preferred because it is felt to be associated with improved tissue healing, decreased risk of complications, and reduced psychological impact of genital surgery. However, advocacy groups and recent ethics literature have argued for deferring genitoplasty until a child reaches decisional maturity. This article reviews these arguments using an ethical framework and discusses the application and challenges of recent disorders of sex development research. RECENT FINDINGS Recent ethics literature and advocacy groups have argued for deferring genitoplasty until a child reaches decisional maturity. As a counterpoint, urological societies have published arguments supporting the practice of early genitoplasty. Data from DSD research lends some guidance but also has a wide range of outcomes, which makes generalizability difficult. A retrospective, multicenter study of 21 individuals with congenital adrenal hyperplasia who underwent feminizing surgery showed no difference between cases and controls in social functioning, parent-child relationships, or sexual fulfillment. Ninety percent of patients thought genitoplasty should occur within the first year of life. In a study of 52 patients with 46,XY and 46,XX DSDs who underwent masculinizing genitoplasty, 57% thought their physical appearance was 'fair' or 'poor,' and problems with sexual function, urinary incontinence, and short penile length were common. SUMMARY Early genitoplasty in children with DSDs is ethically complex, and discordant results in DSD research makes generalizability difficult. There is unlikely to be a universal solution to the issue of early genitoplasty in children with DSDs; families must be supported while they weigh both parental decision-making and the objective of ensuring an open future for their child.
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Affiliation(s)
- Rebecca M Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
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Gardner M, Sandberg DE. Navigating Surgical Decision Making in Disorders of Sex Development (DSD). Front Pediatr 2018; 6:339. [PMID: 30510925 PMCID: PMC6252317 DOI: 10.3389/fped.2018.00339] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022] Open
Abstract
Surgical management of disorders of sex development (DSD) is associated with contentious debate between and within stakeholder communities. While the intent of surgical management of the genitals and gonads is to benefit the patient physically and psychosocially, these goals have not always been achieved; reports of harm have surfaced. Harm experienced by some patients has resulted in the emergence of an activist platform calling for a moratorium on all surgical procedures during childhood-excepting those forestalling threats to life within the childhood years. This ban is not universally endorsed by patient advocacy groups. Parents, meanwhile, continue to need to make decisions regarding surgical options for their young children. Constructive paths forward include implementation of Consensus Statement recommendations that call for comprehensive and integrated team care, incorporating mental health services, and adopting shared decision making.
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Affiliation(s)
| | - David E. Sandberg
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
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Roen K, Creighton SM, Hegarty P, Liao LM. Vaginal Construction and Treatment Providers' Experiences: A Qualitative Analysis. J Pediatr Adolesc Gynecol 2018; 31:247-251. [PMID: 29339194 DOI: 10.1016/j.jpag.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 12/27/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To investigate specialist clinicians' experiences of treating vaginal agenesis. DESIGN Semi-structured interviews. SETTING Twelve hospitals in Britain and Sweden. PARTICIPANTS Thirty-two health professionals connected to multidisciplinary teams (MDTs) including medical specialists and psychologists. INTERVENTIONS AND MAIN OUTCOME MEASURES Theoretical thematic analysis of recorded verbatim data. RESULTS The gynecologist and psychologist interviewees share certain observations including the importance of psychological readiness for and appropriate timing of treatment. Three overlapping themes are identified in our theoretical analysis of the MDT clinicians' talk: (1) the stigma of vaginal agenesis and the pressure to be "normal" can lead patients to minimize the time, effort, physical discomfort, and emotional cost inherent in treatment. (2) Under pressure, treatment might be presented to patients with insufficient attention to the potential psychological effect of the language used. Furthermore, the opportunity to question what is "normal" in sex is generally not taken up. It can be challenging to help the women to transcend their medicalized experiences to come to experiencing their bodies as sexual and enjoyable. (3) The reality of treatment demands, which are not always adequately processed before treatment, can lead to discontinuation and even disengagement with services. CONCLUSION The MDT clinicians in this study emphasized the importance of psychological input in vaginal construction. However, such input should proactively question social norms about how women's genitalia should appear and function. Furthermore, rather than steering patients (back) to treatment, the entire MDT could more explicitly question social norms and help the women to do the same. By shifting the definition of success from anatomy to personal agency, the clinical focus is transformed from treatment to women.
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Affiliation(s)
- Katrina Roen
- Department of Societal Psychology, University of Oslo, Oslo, Norway
| | - Sarah M Creighton
- Women's Health Division, University College London NHS Foundation Trust, London, United Kingdom
| | - Peter Hegarty
- Department of Psychology, University of Surrey, Guildford, United Kingdom
| | - Lih-Mei Liao
- Women's Health Division, University College London NHS Foundation Trust, London, United Kingdom.
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Ernst MM, Gardner M, Mara CA, Délot EC, Fechner PY, Fox M, Rutter MM, Speiser PW, Vilain E, Weidler EM, Sandberg DE. Psychosocial Screening in Disorders/Differences of Sex Development: Psychometric Evaluation of the Psychosocial Assessment Tool. Horm Res Paediatr 2018; 90:368-380. [PMID: 30783028 PMCID: PMC6512800 DOI: 10.1159/000496114] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 12/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/AIMS Utilization of a psychosocial screener to identify families affected by a disorder/difference of sex development (DSD) and at risk for adjustment challenges may facilitate efficient use of team resources to optimize care. The Psychosocial Assessment Tool (PAT) has been used in other pediatric conditions. The current study explored the reliability and validity of the PAT (modified for use within the DSD population; PAT-DSD). METHODS Participants were 197 families enrolled in the DSD-Translational Research Network (DSD-TRN) who completed a PAT-DSD during a DSD clinic visit. Psychosocial data were extracted from the DSD-TRN clinical registry. Internal reliability of the PAT-DSD was tested using the Kuder-Richardson-20 coefficient. Validity was examined by exploring the correlation of the PAT-DSD with other measures of caregiver distress and child emotional-behavioral functioning. RESULTS One-third of families demonstrated psychosocial risk (27.9% "Targeted" and 6.1% "Clinical" level of risk). Internal reliability of the PAT-DSD Total score was high (α = 0.86); 4 of 8 subscales met acceptable internal reliability. A priori predicted relationships between the PAT-DSD and other psychosocial measures were supported. The PAT-DSD Total score related to measures of caregiver distress (r = 0.40, p < 0.001) and to both caregiver-reported and patient self-reported behavioral problems (r = 0.61, p < 0.00; r = 0.37, p < 0.05). CONCLUSIONS This study provides evidence for the reliability and validity of the PAT-DSD. Given variability in the internal reliability across subscales, this measure is best used to screen for overall family risk, rather than to assess specific psychosocial concerns.
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Affiliation(s)
- Michelle M. Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Constance A. Mara
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Patricia. Y. Fechner
- Department of Pediatrics, University of Washington, Seattle Children’s DSD Program, Seattle, Washington
| | - Michelle Fox
- Department of Pediatrics, UCLA School of Medicine, Los Angeles, California
| | - Meilan. M. Rutter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Phyllis W. Speiser
- Department of Pediatrics, Cohen Children’s Medical Center of New York and Zucker School of Medicine at Hofstra University, New Hyde Park, New York
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Erica M. Weidler
- Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona; Accord Alliance, Whitehouse Station, New Jersey
| | | | - David E. Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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