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Utari A, Silberkasten M, Musa S, Hassan S, Sharma R, Bramer W, van der Zwan YG, Drop SLS. Global perspective of psychosocial care of patients with differences of sex development from low-income countries. J Reprod Infant Psychol 2024:1-19. [PMID: 39696731 DOI: 10.1080/02646838.2024.2439926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 11/29/2024] [Indexed: 12/20/2024]
Abstract
OBJECTIVE Management of Differences of Sex Development (DSD) is complex and in resource limited settings the psychosexual and psychosocial aspects of DSD care have received limited attention. This review aims to explore recent literature on psychosocial care of DSD in low and upper middle-income countries (L/UMIC). MATERIALS AND METHODS Scientific databases were searched and papers on management of DSD were reviewed according to predefined inclusion criteria. RESULTS Papers published between January 2010 and July 2024 were screened for eligibility. Seventy studies specifically focusing on psychosexual and psychosocial aspects were identified. In these papers, the following aspects were studied in detail: gender identity, sexual behaviour, quality of life, perception of parents and society, communication and family counselling and socio-cultural and religious aspects. CONCLUSIONS The geographical distribution and volume of studies on the psychosexual and psychosocial aspects of DSD in L/UMIC are mostly originating from East-and South-Asia and South & Central America. The findings underscore the need for integrated and culturally sensitive interventions to support the psychosocial well-being of patients and their families affected by DSD within resource-limited contexts. We highly recommend providing specific guidelines recognising the socio-cultural milieu and resource restricted settings. International collaboration providing education and training should be encouraged.
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Affiliation(s)
- Agustini Utari
- Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Marcelo Silberkasten
- Department of Clinical Psychology, Hospital de Niños Ricardo Gutierrez Buenos Aires, Buenos Aires, Argentina
| | - Salwa Musa
- Department of Pediatrics and Child Health, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan
- Pediatric Endocrine Department, Gaafar Ibn Auf Pediatric Tertiary Hospital, Khartoum, Sudan
| | - Samar Hassan
- Pediatric Endocrine Department, Gaafar Ibn Auf Pediatric Tertiary Hospital, Khartoum, Sudan
| | - Rajni Sharma
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Wichor Bramer
- Medical Library - Erasmus MC, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - Stenvert L S Drop
- Department of Pediatrics, Division Endocrinology, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands
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Moegni F, Nilasari D, Hakim S, Priyatini T, Meutia AP, Hidayah GN. Vulvar-vaginal reconstruction surgery for sexual function in patient with disorders of sex development. Int J Surg Case Rep 2022; 98:107516. [PMID: 36063765 PMCID: PMC9482924 DOI: 10.1016/j.ijscr.2022.107516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction and importance Amenorrhea can be a transient, intermittent, or permanent condition reflecting the overall health condition of a woman. Primary amenorrhea and ambiguous genitalia appearance warrant more comprehensive diagnosis and treatment, especially in those planning to have a married life. Case presentation A case a 24 years old woman was referred to our hospital with a chief complaint of primary amenorrhea. Previously, she was diagnosed with vaginal agenesis. However, a thorough examination revealed ambiguous genitalia and karyotype result of 46, XY. Following several rounds of discussion with the patient, her family, and her partner, she chose to remain a female and even planned to be married following the treatments. A vaginoplasty followed by clitoral reduction was done with a satisfactory result. Clinical discussion Disorders of sex development and differentiation is a rare but devastating condition. Various biological, psychological, and social issues are surrounding those affected by it. The burden was further aggravated for those who are late to discover their condition, especially those planning to be married. Conclusion Comprehensive and multidisciplinary approaches are needed to ensure the best outcome for DSD patients. DSD would have disorders in genital appearance that might need reconstructive vulvar-vaginal surgery. To reconstruct its feature, reconstructive surgery was needed in order to achieve patient's need. The best outcomes for patients are achieved when a comprehensive and multidisciplinary approach is taken.
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Affiliation(s)
- Fernandi Moegni
- Reconstructive Aesthetic Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Indonesia.
| | - Dewita Nilasari
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo National General Hospital, Indonesia
| | - Surahman Hakim
- Reconstructive Aesthetic Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Tyas Priyatini
- Reconstructive Aesthetic Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Alfa Putri Meutia
- Reconstructive Aesthetic Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Gita Nurul Hidayah
- Reconstructive Aesthetic Urogynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Indonesia
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O'Connell MA, Atlas G, Ayers K, Sinclair A. Establishing a molecular genetic diagnosis in children with Differences of Sex Development - a clinical approach. Horm Res Paediatr 2021; 96:128-143. [PMID: 34781289 DOI: 10.1159/000520926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite distinct underlying aetiologies, the clinical phenotypes and hormonal profiles of children with various differences of sex development (DSD) are often similar, which presents challenges to ascertaining an accurate diagnosis on clinical grounds alone. Associated features and important clinical outcomes can, however, vary significantly in different DSD, thus establishing an accurate molecular diagnosis may have important implications for decision-making and management planning in a given individual. Summary The wider availability of next generation sequencing techniques in recent years has led to recommendations for earlier integration of genetic testing in the diagnostic pathway of children with DSD. This review provides a practical overview of the clinical applications, advantages and limitations of the more commonly available diagnostic genetic tests and outlines a suggested approach to testing. The potential clinical implications of a confirmed genetic diagnosis on subsequent management pathways for individuals with DSD, as well as challenges that remain to be addressed are also outlined. Key messages Despite significant improvements in our understanding of the complex genetic pathways that underlie DSD, an accurate diagnosis still eludes many affected individuals. Establishing a molecular diagnosis provides aetiological certainty, enabling improved information for families and individualised clinical management, including monitoring or prophylactic intervention where higher longer-term health risks exist. A stepwise approach to genomic testing is recommended to afford highest diagnostic yield from available resources. Looking forward, collaborative multicentre prospective studies will be required to assess the true impact of a genetic diagnosis on improving clinical care pathways and health, wellbeing and patient-reported outcomes for individuals with DSD.
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Jiwanmall SA, Kattula D. Profile of Siblings with Disorders of Sexual Differentiation and Gender Dysphoria. Indian J Psychol Med 2021; 43:368-369. [PMID: 34385737 PMCID: PMC8327870 DOI: 10.1177/0253717620927895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/14/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Dheeraj Kattula
- Dept. of Psychiatry, Christian Medical College, Bagayam, Vellore, Tamil Nadu, India
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Chen L, Wang J, Lu W, Xiao Y, Ni J, Wang W, Ma X, Dong Z. Characterization With Gene Mutations in Han Chinese Patients With Hypospadias and Function Analysis of a Novel AR Genevariant. Front Genet 2021; 12:673732. [PMID: 34276780 PMCID: PMC8278054 DOI: 10.3389/fgene.2021.673732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that around 10-20% of hypospadias are caused by genetic abnormalities worldwide although the spectrum of associated genes does vary across different ethnicities. The prevalence of hypospadias among the Chinese population has been increasing the last couple of decades. However, the pathogenesis underlying the disease and its associated genetic abnormality remains unclear. Here we performed a genetic analysis of 81 children with karyotype 46, XY and the hypospadias phenotype in order to characterize the genetic components that contribute to the development of hypospadias in Chinese patients. 15 candidate genes, including sex determination genes-SOX9, SRY, NR0B1 (DAX1), NR5A1 (SF1), DHH, sex differentiation genes-AR, SRD5A2, MAMLD1, INSL3, and hypospadias-associated genes-FGF8, FGF10, BMP4, BMP7, ATF3, and MID1 were screened by using next generation sequencing. A total of 18 patients were found to have mutations identified by PCR and sequencing, including 11 cases of SRD5A2 genes, 6 cases of AR genes, and 1 case of MID1 gene, respectively. One novel missense mutation p.I817N was discovered in AR gene. Further molecular analysis found that subcellular localization of the ARI 81 7N was the same as that of wild type ARWT in the absence or presence of hormone. But it led to 50% reduction in AR-induced transcriptional activity in the presence of either the synthetic androgen R1881 or the natural ligand dihydrotestosterone. Our results indicate that SRD5A2 and AR genes are two top candidate genes associated with 46, XY hypospadias in Chinese patients. Further epidemiological and genetic analysis are still needed to further clarify the pathogenesis of hypospadias in Han Chinese patients.
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Affiliation(s)
- Lifen Chen
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Junqi Wang
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenli Lu
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Xiao
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jihong Ni
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Wang
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Ma
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiya Dong
- Department of Pediatrics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Babu R, Shah U. Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis. J Pediatr Urol 2021; 17:39-47. [PMID: 33246831 DOI: 10.1016/j.jpurol.2020.11.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced. METHODS Pubmed/Index medicus were searched for "intersex" [All fields] OR "disorders of sexual differentiation AND "gender identity disorder OR gender dysphoria" [MeSH] for articles published between 2005 and 2020. Typical diagnoses included were congenital adrenal hyperplasia (CAH); complete androgen insensitivity syndrome (CAIS); partial androgen insensitivity syndrome (PAIS); 5 alpha reductase deficiency (5ARD); 17-hydroxysteroid dehydrogenase deficiency (17HSD); mixed gonadal dysgenesis (MGD) and complete gonadal dysgenesis (CGD). GID or gender dysphoria (a strong feeling of dissatisfaction about oneself as male or female) prevalence in DSD patients older than 12 years of age was extracted. Within each condition, GID percentage was compared between female and male rearing. RESULTS The I2statistics for prevalence of GID in DSD showed high heterogeneity with I2 of 93% (95% C.I 90-95%) among the 20 articles included. The overall prevalence of GID among those with DSD was 15% (95% C.I 13-17%). CAH reared females had 4% GID while CAH reared males had significantly higher GID at 15% (p = 0.0056). All CAIS patients were raised as females and the prevalence of GID was 1.7%. GID prevalence was 12% in PAIS raised as females while 25% in those raised as males with no significant difference (p = 0.134). GID was significantly high in 5ARD (53%) and 17HSD (53%) reared as females with half of them virilizing at puberty forcing a gender change. Among sex chromosome DSD 22% of those reared as females had GID while none in those raised as male with no significant difference. CONCLUSIONS GID is low in women with CAH, CAIS and CGD favoring female sex of rearing in these conditions. GID is high in women with 5ARD/17HSD favoring male sex of rearing in these conditions. GID is variable in PAIS or MGD and no recommendations on sex of rearing could be made in these conditions. Each DSD patient is unique and they warrant multi-disciplinary care and long term psycho sexual support.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Utsav Shah
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India
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Das S, Saikia UK, Saikia KK, Sarma D, Choudhury BK, Bhuyan AK, Baro A, Das DV, Appaiah S. "Spectrum of 46 XY Disorders of Sex Development": A Hospital-based Cross-sectional Study. Indian J Endocrinol Metab 2020; 24:360-365. [PMID: 33088761 PMCID: PMC7540835 DOI: 10.4103/ijem.ijem_98_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/25/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) are a wide range of relatively rare conditions having diverse pathophysiology. Identification of an underlying cause can help in treating any coexisting hormone deficiencies and can help with anticipating any other immediate or long-term health concerns. OBJECTIVE To study the clinical and biochemical profile of patients with 46 XY DSD along with androgen receptor (AR) gene mutation status in selected group of patients. METHODS A cross-sectional study was conducted after enrolling the eligible DSD patients. Thorough elicitation of history and detailed clinical examination was done. Assays for luteinizing hormone, follicle-stimulating hormone, testosterone, dihydrotestosterone, androstenedione, AMH & Inhibin B (where indicated), and human chorionic gonadotropin stimulation were done as per protocol. RESULTS In total, 48 patients were included in the study. Ambiguous genitalia (58.3%) followed by hypospadias (33.3%) were common presentation. Androgen biosynthetic defect were the most commonly encountered diagnosis followed by androgen insensitivity syndrome (AIS). Swyer syndrome was diagnosed in 4.2% of cases; partial gonadal dysgenesis, ovotesticular DSD, and vanishing testis syndrome contributed to 2% of cases each. Eight cases (16.7%) who presented with isolated proximal and midshaft hypospadias for whom no diagnosis was found were categorized in the "etiology unclear" group. AR gene mutation analysis designed against specific exons did not yield any results. CONCLUSION 46 XY DSD is a heterogeneous group of patients with a varying age of presentation and a diverse clinical profile. Most patients are reared as males and maintained the same gender identity except in isolated cases. Diagnosis of AIS remains a clinical challenge as a definite hormonal criterion does not exist and genetic mutations in AR gene may be negative. Flanking region sequencing, whole genome sequencing, and promoter region sequencing may reveal pathogenic variants. Variations in other genes regulating AR pathway may also be candidates to be studied.
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Affiliation(s)
- Samiran Das
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Uma K. Saikia
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Kandarpa K. Saikia
- Department of Bioengineering and Technology, GUIST, Gauhati University, Assam, India
| | - Dipti Sarma
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | | | - Ashok K. Bhuyan
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Abhamoni Baro
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Darvin V. Das
- Department of Endocrinology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
| | - Sonali Appaiah
- Department of Endocrinology, St Johns Medical College, Banglore, Karnataka, India
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Dash HR, Rawat N, Das S. Alternatives to amelogenin markers for sex determination in humans and their forensic relevance. Mol Biol Rep 2020; 47:2347-2360. [DOI: 10.1007/s11033-020-05268-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/20/2020] [Indexed: 12/15/2022]
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Kim S, Rosoklija I, Johnson EK. Surgical, Patient, and Parental Considerations in the Management of Children with Differences of Sex Development. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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