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Byers HM, Mohnach LH, Fechner PY, Chen M, Thomas IH, Ramsdell LA, Shnorhavorian M, McCauley EA, Amies Oelschlager AME, Park JM, Sandberg DE, Adam MP, Keegan CE. Unexpected ethical dilemmas in sex assignment in 46,XY DSD due to 5-alpha reductase type 2 deficiency. Am J Med Genet C Semin Med Genet 2017; 175:260-267. [PMID: 28544750 DOI: 10.1002/ajmg.c.31560] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/23/2017] [Accepted: 03/31/2017] [Indexed: 11/10/2022]
Abstract
Sex assignment at birth remains one of the most clinically challenging and controversial topics in 46,XY disorders of sexual development (DSD). This is particularly challenging in deficiency of 5-alpha reductase type 2 given that external genitalia are typically undervirilized at birth but typically virilize at puberty to a variable degree. Historically, most individuals with 5-alpha reductase deficiency were raised females. However, reports that over half of patients who underwent a virilizing puberty adopted an adult male gender identity have challenged this practice. Consensus guidelines on assignment of sex of rearing at birth are equivocal or favor male assignment in the most virilized cases. While a male sex of rearing assignment may avoid lifelong hormonal therapy and/or allow the potential for fertility, female sex assignment may be more consistent with external anatomy in the most severely undervirilized cases. Herein, we describe five patients with 46,XY DSD due 5-alpha-reductase type 2 deficiency, all with a severe phenotype. An inter-disciplinary DSD medical team at one of two academic centers evaluated each patient. This case series illustrates the complicated decision-making process of assignment of sex of rearing at birth in 5-alpha reductase type 2 deficiency and the challenges that arise when the interests of the child, parental wishes, recommendations of the medical team, and state law collide.
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Affiliation(s)
- Heather M Byers
- Division of Medical Genetics, University of Washington, Seattle, Washington
| | - Lauren H Mohnach
- DSD Program, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Patricia Y Fechner
- Division of Endocrinology, Seattle Children's Hospital, Seattle, Washington.,Division of Pediatric Psychology, Seattle Children's Hospital, Seattle, Washington
| | - Ming Chen
- Division of Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Inas H Thomas
- Division of Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Linda A Ramsdell
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | | | - Elizabeth A McCauley
- Department of Psychiatry and Behavior Medicine, University of Washington, Seattle, Washington
| | | | - John M Park
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David E Sandberg
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Margaret P Adam
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Catherine E Keegan
- Division of Genetics, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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Hipp LE, Mohnach LH, Wei S, Thomas IH, Elhassan ME, Sandberg DE, Quint EH, Keegan CE. Isodicentric Y mosaicism involving a 46, XX cell line: Implications for management. Am J Med Genet A 2015; 170A:233-8. [PMID: 26407917 DOI: 10.1002/ajmg.a.37403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 09/08/2015] [Indexed: 01/14/2023]
Abstract
Carriers of isodicentric Y (idicY) mosaicism exhibit a wide range of clinical features, including short stature, gonadal abnormalities, and external genital anomalies. However, the phenotypic spectrum for individuals carrying an idicY and a 46, XX cell line is less clearly defined. A more complete description of the phenotype related to idicY is thus essential to guide management related to pubertal development, fertility, and gonadoblastoma risk in mosaic carriers. Findings from the evaluation of twin females with an abnormal karyotype, 48, XX, +idic(Yq) x2/47, XX, +idic(Yq)/46, XX, are presented to highlight the importance of interdisciplinary care in the management of multifaceted disorders of sex development.
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Affiliation(s)
- Lauren E Hipp
- Department of Internal Medicine, Molecular Medicine & Genetics, University of Michigan, Ann Arbor, Michigan
| | - Lauren H Mohnach
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan.,Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Sainan Wei
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan
| | - Inas H Thomas
- Division of Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Maha E Elhassan
- Division of Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - David E Sandberg
- Division of Pediatric Psychology and Child Health Evaluation & Research (CHEAR) Unit, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Elisabeth H Quint
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Catherine E Keegan
- Division of Genetics, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan
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