Opportunities and challenges with the German act for the protection of children with variations of sex development

In May 2021, the German parliament passed a long-debated law to protect children with variations of sex development/sex characteristics from medically unnecessary surgeries until they are old enough to decide for themselves. This law joins similar laws passed in other countries in recent years and recognizes the rights of people with variations of sex development to self-determination and bodily autonomy. In this article, we discuss the notion of bodily autonomy and examine details of the German legislation in the context of psychosocial care. We focus on the following questions: (1) How may the law help to preserve the genital integrity and future bodily autonomy of newborns with variations of sex development (VSD)? (2) What are the opportunities and challenges of this law? (3) What strategies are needed to implement the law in ways that include medical professionals' knowledge and skills, parental cooperation, and protection for the genital integrity as well as the future genital autonomy of newborns with VSD? We make two main arguments. On the one hand, this law has created a space for a new discourse and discussion on VSD in German society and enables the "wait and see" approach. This approach challenges the traditional "psychosocial emergency" policy aimed at quickly "repairing" atypical genitalia. On the other hand, the law is characterized by significant challenges. For example, it does not address the meaning of bodily autonomy in the context of newborns and their families with VSD, and it overlooks the important distinction between genital appearance, genital function, and gender identity. We offer various educational strategies that can be implemented with different target groups in Germany to meet these challenges and ensure the adequate implementation of this law.

Mental health in people with minority sexual orientations: A meta-analysis of population-based studies

AIMS

To conduct a meta-analysis of population-based studies to quantify the association between sexual minority status (lesbian women, gay men, and bisexual people) and the risk of common mental disorders (depressive disorders, alcohol use disorders (AUD), anxiety disorders, and suicidality).

METHOD

PubMed, PsycInfo, Web of Science, the Cochrane Library Database, the Applied Social Sciences Index and Abstracts, and ProQuest were searched for relevant studies published between 2000 and May 2020. The PRISMA guidelines were followed for selection processes. Twenty-six studies met the inclusion criteria which included a total of 519,414 heterosexuals, 10,178 lesbian/gay people and 14,410 bisexual people.

RESULTS

Lesbian/gay people (ORs between 1.97, 95% [CI = 1.76, 2.19] and 2.89, 95% [CI = 2.41,3.38]) and bisexual people (ORs between 2.70; 95% [CI = 2.21,3.18], and 4.81; 95% [CI = 3.63, 5.99]) had a higher risk for mental disorders than heterosexuals for all investigated diagnostic categories. The risk for depression (OR = 2.70; 95% [CI = 2.21, 3.18]) and suicidality (OR = 4.81; 95% [CI = 3.63, 5.99]) was higher in bisexual compared with lesbian/gay people. Exploratory meta-regressions revealed no evidence for a decrease in mental health differences between people with minority sexual orientations and heterosexuals in more recent years of data assessment, except for AUD.

CONCLUSIONS

These findings clearly suggest disparities in mental health between people with minority sexual orientations and heterosexual people. There is a lack of data regarding a wider spectrum of sexual orientations and mental disorders and studies in non-Western countries.

‘That decision really was mine...'. Self-reported healthcare controversies among intersex persons

Background

After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of ‘optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of ‘full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family.

Methods

Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically.

Results and Conclusions

Findings indicate that while ‘full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.

Psychosocial Approaches and Discursive Gaps in Intersex Healthcare

Background

In the past several decades, conflicting discourses have coexisted in the field of intersex studies, including the pathologizing discourse of the biomedical disciplines and the affirmative, subjective psychosocial discourse of people born with intersex bodies and their advocates. Intersex activists call for a positive discourse and a humanistic healthcare approach that accepts and protects intersex bodily autonomy and change the continuing harmful, traumatic treatments aimed at normalizing variations of sex characteristics (VSC).

Methods

We created a collaborative German-Israeli action study, in with 30 health care professionals, intersex activists and scholars from Israel and Germany, were gathered to learn different perspectives on intersexuality, interact and work together on projects aim to improve the care for intersex people and families.

Results

The participants created different collaborative projects, including “intersex workshops” for caregivers and professionals in Israel and Germany; unique materials for raising an awareness, e.g., booklets on intersex bodies with a positive and affirmative approach and language and an article for health care within the ultraorthodox Jewish community; parents' groups and implementation of programs that aim to build bridges between biomedical professionals, caregivers, parents, and intersex people in Israel and Germany.

Conclusions

The participants increased their knowledge and awareness of and sensitivity to intersex issues, and implemented these in their daily work and practices. The participants acknowledged the differences between the countries, especially in relation to the heightened Israeli use of assisted reproductive technology, which effect on the treatment practices, early genetic diagnosis and the preventive medical attitude. In Germany, more activism for intersex human rights and significant laws which regulate the medical treatment practices.

'That decision really was mine…'. Insider perspectives on health care controversies about intersex/diverse sex development

After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of 'optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of 'full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family. Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically. Findings indicate that while 'full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.

Psychosocial approaches and discursive gaps in intersex healthcare: findings from an Israeli-German action research study

In the past several decades, conflicting discourses have coexisted in the field of intersex studies, including the pathologising discourse of the biomedical disciplines and the affirmative, subjective psychosocial discourse of people born with intersex bodies and their advocates. Intersex activists call for a positive discourse on intersex bodies and a humanistic healthcare approach that accepts and protects intersex bodily autonomy to replace continuing harmful, traumatic treatments aimed at normalising variations of sex characteristics (VSC). Our awareness of the biomedical discursive dominance prompted us to initiate Inter-Care and Awareness, an intercultural German-Israeli action research project. This paper introduces the project and explores intercultural approaches to psychosocial intersex care using an action research framework. We describe how the project's goals, processes and outcomes created educational material on intersex which uses positive language, explores intersex in the Jewish tradition, improves the support offered to parents of intersex children, and examines cross-cultural differences that arose in the encounters between the Israeli and German participants. The analysis points to sociocultural themes that reflect intersex people's current status in Israel and Germany. Implications regarding the implementation of similar projects in other countries are discussed.

Psychosocial care and support in the field of intersex/diverse sex development (dsd): counselling experiences, localisation and needed improvements

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.

Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with Gender Dysphoria

Research provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis. This study examined the relationship between social transition status and psychological functioning outcomes in a clinical sample of children with a GD diagnosis. Psychological functioning (Child Behavior Checklist; CBCL), the degree of a social transition, general family functioning (GFF), and poor peer relations (PPR) were assessed via parental reports of 54 children (range 5-11 years) from the Hamburg Gender Identity Service (GIS). A multiple linear regression analysis examined the impact of the social transition status on psychological functioning, controlled for gender, age, socioeconomic status (SES), PPR and GFF. Parents reported significantly higher scores for all CBCL scales in comparison to the German age-equivalent norm population. Peer problems and worse family functioning were significantly associated with impaired psychological functioning, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.

Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent

INTRODUCTION

Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion.

AIM

The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions.

METHODS

A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis.

MAIN OUTCOME MEASURE

Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making.

RESULTS

The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence.

CONCLUSION

The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.

[Autism Spectrum Disorders and Gender Dysphoria Among Children and Adolescents: Systematic Review on the Co-Occurrence]

OBJECTIVE

The review systematically reviews the literature on co-occurring gender dysphoria/gender variance and autism spectrum disorder among children and adolescents.

METHODS

A systematic literature search was conducted for the years 1946 to December 2018.

RESULTS

144 publications could be identified in the literature search. Out of these, 22 publications met the inclusion criteria for the systematic review. 4.7 to 13.3 % of the children and adolescents with primarily diagnosed gender dysphoria/variance examined in the studies also had an autism diagnosis. In samples of children and adolescents with primarily diagnosed autism gender variance was overrepresented with a prevalence of 4 to 6.5 %.

CONCLUSION

The results of the systematic review point towards an overrepresentation of co-occurring gender dysphoria/variance and autism spectrum disorder. Methodological and clinical implications are discussed.

Standardised data collection for clinical follow-up and assessment of outcomes in differences of sex development (DSD): recommendations from the COST action DSDnet

The treatment and care of individuals who have a difference of sex development (DSD) have been revised over the past two decades and new guidelines have been published. In order to study the impact of treatments and new forms of management in these rare and heterogeneous conditions, standardised assessment procedures across centres are needed. Diagnostic work-up and detailed genital phenotyping are crucial at first assessment. DSDs may affect general health, have associated features or lead to comorbidities which may only be observed through lifelong follow-up. The impact of medical treatments and surgical (non-) interventions warrants special attention in the context of critical review of current and future care. It is equally important to explore gender development early and refer to specialised services if needed. DSDs and the medical, psychological, cultural and familial ways of dealing with it may affect self-perception, self-esteem, and psychosexual function. Therefore, psychosocial support has become one of the cornerstones in the multidisciplinary management of DSD, but its impact remains to be assessed. Careful clinical evaluation and pooled data reporting in a global DSD registry will allow linking genetic, metabolomic, phenotypic and psychological data. For this purpose, our group of clinical experts and patient and parent representatives designed a template for structured longitudinal follow-up. In this paper, we explain the rationale behind the selection of the dataset. This tool provides guidance to professionals caring for individuals with a DSD and their families. At the same time, it collects the data needed for answering unsolved questions of patients, clinicians, and researchers. Ultimately, outcomes for defined subgroups of rare DSD conditions should be studied through large collaborative endeavours using a common protocol.

Variations of sex development: The first German interdisciplinary consensus paper

INTRODUCTION

The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly 'feminizing' elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female. Protests by advocacy groups for the most part as well as the results of outcome studies have shown that the development of affected persons may be very different to what has been expected and often does not result in the intended clear female or male gender identity as had been intended. It, therefore, seemed a matter of urgency to implement this new awareness as well as the ethical and personal human rights perspectives in the recommendations for the medical and psychosocial management of diverse sex development (DSD) in the future.

STUDY DESIGN

In 2012, an interdisciplinary group of German academics engaged in the field of DSD decided to work on a consensus paper for this topic. It involved the participation of all faculties and non-scientific groups dealing with DSD, in particular advocacy and service-user groups. In a structured consensus, process recommendations were developed based on scientific literature as well as personal experiences of clinicians and affected individuals.

RESULTS

Finally, 37 recommendations were agreed on. The strength of consensus is reflected in the degree of agreement as expressed in percentages.

CONCLUSION

The introduction of the consensus paper reflects on the emerging paradigm shift and the necessity for a more open view of gender within society. The paper is intended to aid the performance of appropriate diagnostics in DSD-affected newborns and especially to help parents and affected persons cope with the biological and social consequences of DSD. With regard to medical or surgical therapy, it gives information about the most recent treatment trends.

Caring for individuals with a difference of sex development (DSD): a Consensus Statement

The term differences of sex development (DSDs; also known as disorders of sex development) refers to a heterogeneous group of congenital conditions affecting human sex determination and differentiation. Several reports highlighting suboptimal physical and psychosexual outcomes in individuals who have a DSD led to a radical revision of nomenclature and management a decade ago. Whereas the resulting recommendations for holistic, multidisciplinary care seem to have been implemented rapidly in specialized paediatric services around the world, adolescents often experience difficulties in finding access to expert adult care and gradually or abruptly cease medical follow-up. Many adults with a DSD have health-related questions that remain unanswered owing to a lack of evidence pertaining to the natural evolution of the various conditions in later life stages. This Consensus Statement, developed by a European multidisciplinary group of experts, including patient representatives, summarizes evidence-based and experience-based recommendations for lifelong care and data collection in individuals with a DSD across ages and highlights clinical research priorities. By doing so, we hope to contribute to improving understanding and management of these conditions by involved medical professionals. In addition, we hope to give impetus to multicentre studies that will shed light on outcomes and comorbidities of DSD conditions across the lifespan.

Coping With Diverse Sex Development: Treatment Experiences and Psychosocial Support During Childhood and Adolescence and Adult Well-Being

Objectives

The purpose of this exploratory, retrospective, and correlational study was to examine the relationships between childhood treatment experiences, parental care, and social support, and outcome in adults with different diverse sex development (DSD).

Methods

The data of 69 participants from an exploratory questionnaire were collected in a retrospective German study.

Results

The majority received medical treatment in relation to their DSD during childhood and adolescence. Seventy percent reported having had a best friend and 29% a confidant during childhood. Sixty-one percent showed clinically relevant psychological distress, and 45% reported suicidal thoughts at least at one point in their lives. Quality of parental care and having had a best friend correlated positively with adult outcome, whereas treatment experiences correlated with aspects of impaired adjustment.

Conclusions

Social support and DSD-related treatment experiences appear to have an impact on adult well-being. Appropriate psychosocial care including peer-to-peer support should be made available to children with DSD and their families.

Sexual quality of life of individuals with disorders of sex development and a 46,XY karyotype: a review of international research

This article summarizes the current state of research on Sexual Quality of Life (SexQoL) of adults with 46,XY Disorders of Sex Development (DSD)/Intersexuality. An extensive literature search yield 21 studies published between 1974-2007, examining sexual aspects in individuals with 46,XY DSD. However, many of them lack methodological quality. The results are inconsistent but overall indicate that SexQoL of individuals with 46,XY DSD is impaired, particular with regard to sexual dysfunctions and sexual satisfaction. Future studies on SexQoL should focus more on qualitative aspects of sexuality and investigate medical and psychosocial risk factors such as sex-corrective surgery and parental bonding.

Encephalitis related to primary varicella-zoster virus infection in immunocompetent children

INTRODUCTION

Encephalitis is a rare complication of primary varicella-zoster virus (VZV) infection in immunocompetent children.

METHODS

The clinical and laboratory findings of two girls with VZV-related encephalitis are reported.

RESULTS

Both children presented with focal epileptic seizures, corresponding to cortical/subcortical as well as white matter lesions. The first showed a typical vesicular skin rash. She was easily diagnosed and made a rapid recovery during acyclovir and steroid treatment. In the second girl, a preceding measles-mumps-rubella virus vaccination and the absence of skin vesicles were misleading with respect to the diagnosis, which was finally proven by IgG seroconversion and intrathecal synthesis of IgG antibodies to VZV. She developed left parieto-occipital tissue necrosis and recovered only transiently during initial acyclovir/steroid treatment. Eight weeks after onset, progressive white matter demyelination and the occurrence of erythema nodosum in the lower limbs necessitated a second 4-month course of oral steroids. The VZV PCR from cerebrospinal fluid was negative in both children.

CONCLUSIONS

Primary VZV infection may cause severe encephalitis that may occur without skin vesicles and lead to a chronic course with systemic vasculitis. The coincidence of vaccination and neurologic diseases offers no proof per se of a causal relationship.

Peripheral decrease and pulmonary homing of CD4+CD45RO+ helper memory T cells in cystic fibrosis

Interstitial lung disease, although of prognostic impact for patients with cystic fibrosis (CF), remains difficult to assess without histopathologic investigations. As changes of peripheral blood lymphocyte subsets (LS) may accompany severe systemic lymphocyte immune responses, we compared peripheral LS of 44 patients with CF, 23 non-CF patients with recurrent pulmonary infections and 83 healthy controls (flow cytometry; CD3, CD19, CD16, CD56, CD4, CD8, CD11b, CD45RA, CD45RO, HLA-DR and CD25 antigens). Additional immunohistochemistry was performed on lung tissue of four CF patients aged 0.5, 12, 17 and 20 years, respectively. Patients with CF showed low absolute counts of CD4+CD45RO+ memory helperT cells, CD16+CD56+ NK cells, CD8+ and interleukin-2 receptor-positive T cells in peripheral blood (P < 0.001). Similar changes were registered in the non-CF patients with pulmonary infections, indicating that those were not specific for CF. Immunohistochemistry showed activation of bronchus-associated lymphoid tissue with interstitial accumulation of CD4+CD45 RO+ T cells in the three older patients. Patients with CF show marked changes of peripheral blood LS which are presumably not CF-specific and may mirror homing to lung tissue in the course of interstitial lung disease. Further research should evaluate its usefulness in monitoring progression of lung disease in CF.

Effects of gallium and mercury ions on transport systems

Mercury was previously shown to exert toxic effects by influencing ion channels and transporters in the kidney and brain. Gallium alloys were suggested as less toxic restorative materials. To compare the toxicity of gallium ions with those of mercury ions, we applied gallium nitrate Ga(NO3)3 (0.1-100 microM and mercuric chloride (HgCl2) (0.001-10 microM) to Xenopus oocytes expressing mammalian ion channels and transport proteins. Mercury (10 microM) inhibited the K+-channels ROMK and HERG, the phosphate transporter NaPi-3, the amino acid transporter rBAT, the cation transporter OCT-2, and the osmolyte transporter BGT. It activated the I(Ks)-channel but did not affect the Na+-channel ENaC, the anion channel NaPi-1, and the glucose transporter SGLT-1. Gallium was without significant effect on the channels and on SGLT1, NaPi-3, and rBAT, but inhibited BGT and OCT-2. In conclusion, both Hg2+ and Ga3+ may exert toxic effects on transport systems, which may partially explain their cytotoxic effects.

[Capacity limitation and intellectual ability]

In a study examining the influence of cognitive capacity limitation on intellectual ability, 124 university students were subjected to 7 computer-based tests in which cognitive demands were manipulated by varying the number of required ordering, arithmetic, and memory operations, respectively. Intelligence data were obtained by forming a composite score from Raven's Advanced Progressive Matrices and the Berlin Intelligence Structure Test. Increases in cognitive demands led to increases in reaction times and number of errors as well as to increases in common variance and in correlations between intelligence and number of errors in 5 and 2 (of 5) comparisons, respectively, while correlations between intelligence and reaction time were found to decrease with increasing task demands in 3 comparisons. All correlations were reduced considerably when storage capacity and coordination efficiency were partialled out. These findings suggest a relationship between capacity limitation and intellectual ability.

The contributions of memory and attention processes to cognitive abilities

In two experiments, the contributions of memory and attention processes to the cognitive abilities of reasoning and perceptual speed were investigated. Two measures of speed of information retrieval from long-term and short-term memory (Posner paradigm, Sternberg paradigm) and two attention measures (continuous attention test, attention switching test) were included in the first experiment (N = 220). The memory tests led to correlations with the measures of cognitive abilities, whereas the attention test did not. The same tests as well as one additional memory test and one attention test (working memory test, test of covert orientation) were administered in the second experiment (N = 116). Again, the memory tests led to the larger correlations with the measures of cognitive abilities. Two components were obtained in components analysis, of which the first was characterized by high loadings of the memory tests and the second by high loadings of the attention tests. Only the memory component contributed to the prediction of cognitive abilities.

Experiences and expectations in evaluating preparation for an examination

The predictability of the evaluation of preparing for an oral examination by means of self-concept and self-esteem as well as optimism and self-efficacy was investigated in a sample of 49 university students. Self-concept was measured by Frankfurter Selbstkonzeptskalen, self-esteem by the 16PF-O scale, personal optimism, social optimism, and self-efficacy by Fragebogen für Personalen Optimismus und Sozialen Optimismus--Erweitert, and the evaluation of the preparation by a self-report sheet. Data were collected 5 wk. before the examination. The self-report sheet was given again one week before the examination. Significant correlations of self-report scores with self-concept scores as well as 16PF-O scores representing past experiences were found for the first assessment. The correlations with personal optimism scores and self-efficacy scores representing expectations were also significant for the second assessment.

[Effects of knowledge acquisition on verbal linearization about spatial orientation]

This paper deals with determinants of linearization in spatial communication. The well-known linearization principles, such as the principle of natural order, primarily emphasize features of the given information. We assume that verbal linearization is in addition influenced by the speakers' knowledge acquisition. Six experiments with a total of 272 participants are reported here. A particular spatial constellation was presented to the participants, who were asked to talk about it afterwards. The linearizations then produced were defined as dependent variables. The results show that the linearizations were influenced by the speaker's experience with the configuration (according-to-experience effect) and also demonstrate the importance of the first encounter (anchor effect). Further characteristics of the effects mentioned above are described and discussed regarding memory research and psycho-linguistics.

Cognitive bias of optimism and its influence on psychological well-being

An investigation of the cognitive bias observed in optimism and the influence of optimism on psychological well-being was conducted. The cognitive bias was assumed to be related to the repressive style of information processing, represented by the trait scale of the State-Trait Anxiety Inventory and the Social Desirability scale. Optimism and well-being were measured by the Life Orientation Test and the Social Optimism scale as well as by the Life Satisfaction and Depression scales, respectively. These scales were applied to a sample of 200 individuals. Trait Anxiety and Social Desirability led to a high multiple correlation with the Life Orientation Test (R = .54) and a moderate multiple correlation with the Social Optimism scale (R = .30). Higher correlations were obtained for the expectation of a positive than of a negative future. Both the Life Orientation Test and the Social Optimism scale contributed to the high multiple correlation with psychological well-being (R = .52).

Visual search, reaction time, and cognitive ability

The contributions of visual search to reaction time and cognitive ability were investigated with 45 subjects. Visual search was assessed via eye movements. The electrooculogram was recorded while a subject located letters arranged in a large display. Reaction time was obtained for a search task. A reasoning and a space scale served to assess cognitive ability. Substantial correlations of number, amplitude, and velocity of saccades with reaction time were obtained. Significant correlations of scores on ability scales with reaction times and amplitudes of saccades were also observed. Obviously, subjects of higher ability showed amplitudes better adjusted to the distances between the letters than those of lower ability.

Effects of a phytopreparation from Helleborus niger on immunocompetent cells in vitro

Extracts of Helleborus species are used as phytopreparations with immunostimulatory properties in Romanian traditional medicine. In Germany, Helleborus niger is used in homeopathy and as an adjuvant therapy in the treatment of tumor patients in anthroposophical medicine. In vitro application of an aqueous extract from Helleborus niger resulted in a slight induction of sister chromatid exchanges (SCE) in cultured peripheral blood mononuclear cells (PBMC) from healthy individuals, an effect associated with a slight increase of the [3H]thymidine uptake in the DNA of isolated lymphocytes. Since the cytokines interleukin (IL)-2 and tumor necrosis factor (TNF)-alpha were reported to increase the number of SCE, we measured the concentrations of these cytokines in the supernatants of cultured PBMC treated with the plant extract. Here, no significant changes were observed as compared with the controls, but a trend to higher supernatant concentrations of TNF-alpha in six out of ten individuals was noted. Compared with lymphocytes treated with the alkylating substance, cyclophosphamide, the increase of the SCE levels induced by the plant extract is weak. The relevance of this DNA destabilizing property remains to be clarified.

Differences in the apoptosis-inducing properties of Viscum album L. extracts

Viscum album L. (mistletoe) extracts are widely used in adjuvant cancer therapy. In contrast to purified components, such as mistletoe lectins and viscotoxins, whole plant extracts of mistletoe resulted in DNA stabilizations in cyclophosphamide-treated lymphocytes but also provided cytotoxicity in tumour cells and lymphocytes. The killing capacities of mistletoe extracts were host tree-specific and not correlated with mistletoe lectin or viscotoxin content. In human lymphocytes, only mistletoe lectins induced a pathway of apoptotic killing. Within 72 h, the lectin B chains also increased the number of lymphocytes undergoing apoptosis. This finding suggests that inhibition of protein synthesis by the A chain of the hololectin may accelerate a receptor-mediated killing pathway induced by the B chains. An unexpected finding was related to the mistletoe-mediated killing, which was more effective against CD8+T cells with an activated phenotype than CD19+ B cells and CD4+ T cells. In vitro treatment of human neutrophils with mistletoe resulted in a slight decrease of phagocytosis and burst activity. The observed dose-dependent occurrence of two neutrophil subsets with different burst activities indicates differences in their susceptibility to mistletoe and suggests the implication of an induction of the apoptotic killing pathway.

Oculo-bulbar myasthenia gravis induced by cytokine treatment of a patient with metastasized renal cell carcinoma

OBJECTIVE

The occurrence of autoimmune diseases or deterioration of pre-existing disorders has recently been described after cytokine treatment. The present report gives evidence for acquired myasthenia gravis induced by externally administered interferon-alpha and interleukin-2 in a patient with metastasized renal cell carcinoma. Electromyographic investigations did not reveal generalised myasthenia gravis. However, a highly elevated titre of antibodies against the human acetylcholine receptor and a significant improvement in clinical symptoms during therapy with anticholinesterase drugs, combined with a decremental response in electronystagmography, indicated an intermittent mainly oculo-bulbar form of myasthenia gravis.

Induction of apoptosis in human lymphocytes treated with Viscum album L. is mediated by the mistletoe lectins

Viscum album L. (VAL) is a phytopreparation used in adjuvant cancer therapy with both immunostimulatory and DNA stabilizing properties at low drug concentrations and cytostatic/cytotoxic properties at higher concentrations. The present work examines the cytotoxic effects of VAL extracts produced from mistletoes grown on different host trees and of purified toxic proteins from VAL, such as the D-galactose-specific lectin I (ML I), the N-acetyl-D-galactosamine-specific ML II and ML III, and crude viscotoxins towards cultured human lymphocytes. The decrease in the number of cultured lymphocytes and blast cells treated with whole plant extracts from VAL was host tree-specific. Nevertheless, there was no close correlation to the content of MLs or viscotoxins. Using the purified proteins, it became obvious that the cell killing was mediated by the induction of apoptosis, as measured by the appearance of a hypodiploid DNA peak using flow cytometry. ML III was the most effective to induce apoptosis, followed by ML II and ML I, while the viscotoxins and oligosaccharides from VAL did not. By measuring the surface expression of IL-2R alpha chains, transferrin receptors and APO-1/Fas molecules on non-apoptotic T cells, no significant changes were observed at low ML concentrations (1 ng/ml), but their decrease at higher ones. Our findings suggest that there might be at least two different ways of cell killing operative in VAL-mediated cytotoxicity: (a) the typical apoptotic cell death with the appearance of hypo-diploid nuclei, and (b) a direct or indirect killing by damaging the cell membrane with subsequent influx of Ca2+ and of the DNA intercalating dye propidium iodide and cell shrinkage. These effects might not be exclusive, as they probably occur simultaneously.

Sister chromatid exchange-inducing DNA lesions and depression of activation markers on the surface of cultured peripheral blood mononuclear cells after the addition of streptococcal pyrogenic exotoxins A and C

Cultivation of peripheral blood mononuclear cells (PBMC) in the presence of streptococcal pyrogenic exotoxins (SPE) A and C resulted in a significant induction of sister chromatid exchange (SCE)-inducing DNA lesions. Concomitantly, the expression of interleukin-2 receptor alpha chain (IL-2R alpha chain), transferrin receptor (TfR), and major histocompatibility complex class II molecule HLA-DR on the surface of phytohemagglutinin-activated T cells from whole blood culture cells (WBCC) significantly decreased within 72 h, that is at least two cell cycles, whereas unstimulated T cells from WBCC did not express these markers but had lost their CD3 molecules, an effect reported to precede apoptosis as part of a T cell inactivation pathway. However, no apoptotic cells were observed within a cultivation period of 120 h. We observed clearcut differences in the responses towards SPE A in WBCC and isolated lymphocytes, since SPE A-treated lymphocytes showed an increase in the [3H]thymidine incorporation and did express IL-2R alpha chain and TfR on their cell surface. Regardless of the precise underlying mechanism, T cells from WBCC seem to be in a state of functional incompetence. The data presented here are the first to provide strong evidence that streptococcal toxins produce SCE-inducing DNA lesions in PBMC, an effect that might contribute to the process of immune cell lethality in streptococcal toxic shock-like syndrome and could be of pivotal importance in the pathogenesis of severe streptococcal disease.

Effects of Viscum album L. on cyclophosphamide-treated peripheral blood mononuclear cells in vitro: sister chromatid exchanges and activation/proliferation marker expression

Based on recently published data, Viscum album L. (VAL) extracts have been shown to provide a DNA stabilizing effect which seems to be restricted to the peripheral blood mononuclear cells (PBMC). We have now investigated whether VAL exerts effects of cellular protection for phytohemagglutinin-activated PBMC treated with cyclophosphamdie (CP) in vitro. The addition of VAL resulted in a slight reduction of CP-induced sister chromatid exchanges of cultured PBMC from healthy individuals. The incubation with CP significantly reduced the expression of the low affinity interleukin-2 receptor (IL-2R alpha chain) and of transferrin receptor (TfR) on PHA-stimulated T lymphocytes. The addition of 10 micrograms/ml VAL was protective against the CP-induced depression of IL-2R alpha chain and TfR expression on these cells. The simultaneous addition of CP and purified VAL components, such as ML I, ML II/III, and viscotoxins did not significantly change expression of IL-2R alpha chain and TfR on T cells. Thus, so far undefined VAL components might be responsible for the observed protection effects of the whole plant extract. The results presented here should encourage investigation of this drug, which might become an interesting adjuvant in cancer therapy.

Effect of task demand and stimulus relevance on preattentive processing

Evidence of cognitively controlled processes influencing preattentive processes is provided. In the first experiment, preattentive processing associated with a discrimination task was compared with that associated with a reaction task. An increase in processing time due to preattentive processes was only found for the discrimination task. In the second experiment, the effects of different amounts of stimulus relevance on preattentive processing were investigated. Stimulus relevance was varied by changing the spatial and temporal distance in cognitively controlled processing. The relevance of the stimulus was proportional to the amount of preattentive processing. It was concluded that the influence of cognitively controlled processing on preattentive processing is moderated by task demand and stimulus relevance. These results are based on observations concerning processing time.

Recombinant human granulocyte colony-stimulating factor does not influence distribution or sister chromatid exchange frequency of proliferating mononuclear cells of the peripheral blood

Phytohemagglutinin-stimulated peripheral blood mononuclear cells (PBMC) were treated with increasing concentrations of filgrastim, the unglycosylated methionine granulocyte colony-stimulating factor of man (rhG-CSF), and cultured for 72 h. There were no impaired proliferation or differentiation of proliferating PBMC, no impaired expression of activation markers such as the low-affinity interleukin 2 receptor and transferrin receptor, and no induction of sister chromatid exchanges. Under these conditions, no effects of a general DNA destabilization of peripheral blood leukocytes was observed. Thus, longterm administration of therapeutical concentrations of rhG-CSF should not produce severe mutagenic effects.