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Gardner M, Khorashad BS, Lee PA, Kogan BA, Sandberg DE. Recommendations for 46,XX Congenital Adrenal Hyperplasia Across Two Decades: Insights from the North American Differences of Sex Development Clinician Survey. Arch Sex Behav 2024:10.1007/s10508-024-02853-1. [PMID: 38684620 DOI: 10.1007/s10508-024-02853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 05/02/2024]
Abstract
Several aspects of clinical management of 46,XX congenital adrenal hyperplasia (CAH) remain unsettled and controversial. The North American Disorders/Differences of Sex Development (DSD) Clinician Survey investigated changes, over the last two decades, in clinical recommendations by specialists involved in the management of newborns with DSD. Members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology participated in a web-based survey at three timepoints: 2003-2004 (T1, n = 432), 2010-2011 (T2, n = 441), and 2020 (T3, n = 272). Participants were presented with two clinical case scenarios-newborns with 46,XX CAH and either mild-to-moderate or severe genital masculinization-and asked for clinical recommendations. Across timepoints, most participants recommended rearing the newborn as a girl, that parents (in consultation with physicians) should make surgical decisions, performing early genitoplasty, and disclosing surgical history at younger ages. Several trends were identified: a small, but significant shift toward recommending a gender other than girl; recommending that adolescent patients serve as the genital surgery decision maker; performing genital surgery at later ages; and disclosing surgical details at younger ages. This is the first study assessing physician recommendations across two decades. Despite variability in the recommendations, most experts followed CAH clinical practice guidelines. The observation that some of the emerging trends do not align with expert opinion or empirical evidence should serve as both a cautionary note and a call for prospective studies examining patient outcomes associated with these changes.
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Affiliation(s)
- Melissa Gardner
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Behzad Sorouri Khorashad
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College and Center, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA.
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
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Peng L, Chen Y, Hu J, Zhao Y, Qin F. Clinical characteristics and surgical treatment of children with 45, X/46, XY differences of sex development. J Pediatr Urol 2024:S1477-5131(24)00148-7. [PMID: 38555233 DOI: 10.1016/j.jpurol.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study retrospectively analyzes the clinical data of 18 children with 45,X/46,XY differences of sex development (DSD), summarizes their clinical features and explores gonadal and Müllerian duct remnants surgical treatment methods. METHODS The clinical data of 18 children with karyotype 45,X/46,XY diagnosed in the Department of Urology of Hunan Children's Hospital from March 2011 to October 2021 were collected. All children underwent HCG stimulation testing, laparoscopic exploration, urethroscopy and bilateral gonadal biopsy. After DSD multidisciplinary team (MDT) meeting, some children underwent gonadectomy and genitalia reconstructive surgeries. RESULTS The median age at first diagnosis was 1 year and 4 months (range: 10 months ∼ 16 years and 3 months). 5 children presented with female gender; they all maintained their gender assignment. The external masculinisation score (EMS) of patients raised as female was 1 (0∼3) [median (range)]. 13 children presented with male gender, 10 maintained a male gender, 3 were assigned a neutral gender. The EMS of the children raised as male was 5 (2-8) [median (range)], the EMS of the children raised as neutral gender was 4 (3.5-9.5) [median (range)]. The HCG stimulation test was positive in 11 cases, partially positive in 2 case, and negative in 5 cases. There was no relationship between the percentage of chimerism (45X ratio) and the appearance and severity of genital abnormalities. (t=-1.08, P=0.298). There was 1 case of complete gonadal dysgenesis (CGD), 10 cases of mixed gonadal dysgenesis (MGD), 5 cases of partial gonadal dysgenesis (PGD), 1 case of bilateral normal testes and 1 case of ovotesticular DSD (split-lateral type). No gonadal specimen showed germ cell tumor changes. Five cases selected to maintain the female gender, among which 3 cases underwent bilateral gonadectomy and genitalia reconstructive surgeries. Among the 10 children who chose to maintain the male gender, unilateral streak gonadectomy was performed in 4 (57.1%) with MGD, unilateral dysgenetic orchiectomy in 1 (25%) with PGD, and right ovariectomy in 1 with OTDSD. Nine of them underwent genitalia reconstructive surgeries. Four of them preserved their uterus and vagina did not have any complications during the follow-up period. CONCLUSION Hypospadias combined with cryptorchidism and residual Müllerian duct structures is the most common phenotype of children with 45, X/46, XY DSD. Mixed gonadal dysgenesis (MGD) is the most common gonadal type. Gender assignment should be carefully selected after a thorough evaluation, while genitalia reconstructive surgery can be considered in selected patients. In children who choose the male gender, the Müllerian duct can be preserved.
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Affiliation(s)
- Liucheng Peng
- Department of Urology, College of Pediatrics, University of South China, Hunan Children's Hospital, No.86 Ziyuan Road, Yuhua District, Changsha, Hunan 410007, China.
| | - Yifu Chen
- Department of Urology, College of Pediatrics, University of South China, Hunan Children's Hospital, No.86 Ziyuan Road, Yuhua District, Changsha, Hunan 410007, China.
| | - Jianjun Hu
- Department of Urology, College of Pediatrics, University of South China, Hunan Children's Hospital, No.86 Ziyuan Road, Yuhua District, Changsha, Hunan 410007, China.
| | - Yaowang Zhao
- Department of Urology, College of Pediatrics, University of South China, Hunan Children's Hospital, No.86 Ziyuan Road, Yuhua District, Changsha, Hunan 410007, China.
| | - Feng Qin
- Department of Urology, College of Pediatrics, University of South China, Hunan Children's Hospital, No.86 Ziyuan Road, Yuhua District, Changsha, Hunan 410007, China.
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Kalfa N, Nordenström J, De Win G, Hoebeke P. Adult outcomes of urinary, sexual functions and fertility after pediatric management of differences in sex development: Who should be followed and how? J Pediatr Urol 2024:S1477-5131(24)00052-4. [PMID: 38423920 DOI: 10.1016/j.jpurol.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/19/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.
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Affiliation(s)
- Nicolas Kalfa
- Département de Chirurgie Infantile, Service de Chirurgie Viscérale et Urologie Pédiatrique, CHU de Montpellier, Montpellier, France; Centre de Référence Maladies Rares DEVGEN Constitutif Sud, CHU de Montpellier, Montpellier, France; UMR 1302 Institute Desbrest of Epidemiology and Public Health, INSERM, Univ Montpellier, Montpellier, France.
| | - Josefin Nordenström
- Department of Pediatric Surgery/Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunter De Win
- Department of Urology, University Hospital Antwerp, Edegem, Belgium; Astarc, Faculty of Medicine and Health Science, University of Antwerp, Belgium; Adolescenty Urology, University College London Hospitals, London, UK
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
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Baskin LS, Cao M, Li Y, Baker L, Cooper CS, Cunha GR. Ovotesticular cords and ovotesticular follicles: New histologic markers for human ovotesticular syndrome. J Pediatr Urol 2024:S1477-5131(23)00572-7. [PMID: 38218629 DOI: 10.1016/j.jpurol.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/15/2024]
Abstract
INTRODUCTION The presence of an ovotestis is a rare difference of sex development. The diagnosis can be difficult with the gold standard being the presence of both testicular cords and ovarian follicles within the same gonad. OBJECTIVE Herein we describe two new markers of ovotesticular syndrome: ovotesticular cords and ovotesticular follicles. STUDY DESIGN Twenty human gonads with a previous diagnosis of ovotestis were re-stained with markers for testicular cords (SOX9, TSPY, SALL4, DDX4, cP450, AR, α-actin) and ovarian tissue (FOXL2, SALL4, DDX4). Ovotesticular cords were defined as structures expressing both testicular Sertoli cell marker (SOX9) and an ovarian follicular cell marker (FOXL2), and in Y chromosome positive specimens, TSPY-positive testicular germ cells. Ovotesticular follicles were defined as a hybrid ovarian follicle containing FOXL2-positive granulosa cells and a central oocyte, but also containing cells expressing the testicular Sertoli cell marker, SOX9, intermingled within FOXL2-positive granulosa cells and male and female germ cells. RESULTS Six of twenty ovotestis did not meet our criterion for the diagnosis of ovotestis lacking the histologic evidence of both testicular and ovarian tissue. The remaining 13 patients in which 14 separate specimens were evaluated, contained ovotestis defined by the presence of testicular cords and ovarian follicles. Eleven of the 14 ovotestis specimens (79 %) contained ovotesticular cords. Four of 11 ovotestis specimens (36 %) contained ovotesticular follicles. DISCUSSION We recommend using eight immunohistochemical markers to diagnose an ovotestis: 1) SOX9, TSPY, SALL4, DDX4, cytochrome P450, AR, smooth muscle α-actin for the testicular component and FOXL2 and SALL4, DDX4 for the ovarian component. SOX9 and TSPY (useful only in the presence of a Y karyotype) are specific testicular markers and FOXL2 the only specific ovarian marker. We found ovotesticular cords and ovotesticular follicles in both human bipolar and mixed ovotestis specimens both with and without the presence of the Y chromosome. The clinical significance of ovotesticular cords and follicles remains unknown. We did not observe any obvious abnormalities in cellular architecture with the juxtaposition of testicular cells and ovarian cells. CONCLUSION We have identified two new structures in humans with ovotestis, ovotesticular cords and ovotesticular follicles (Figure), which appears to be additional markers to facilitate the diagnosis of ovotesticular gonads.
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Affiliation(s)
| | - Mei Cao
- UCSF, San Francisco, CA, USA
| | - Yi Li
- UCSF, San Francisco, CA, USA
| | - Linda Baker
- Nationwide Children's Hospital, Columbus, OH, USA
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Zhou AN, Huang KJ, Howard TL. Beyond Race, Sex, and Gender: Mental Health Considerations of Transgender Youth of Color, Intersex Youth, and Nonbinary Youth. Child Adolesc Psychiatr Clin N Am 2023; 32:683-705. [PMID: 37739628 DOI: 10.1016/j.chc.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
This article explores how race, sex, and gender are better thought of as a continuum rather than binary categories. Starting with a discussion of intersectionality, we examine the importance of ethnic-racial identity and explore unique cultural considerations for working with Black, Latinx, and AAPI transgender and nonbinary youth. We then examine intersex youth and variations of sex development, as well as specific challenges they face. Finally, we explore nonbinary gender identities and the importance of individually tailoring affirming interventions. For all sections, we highlight the strengths and resilience of the youth and offer clinical recommendations for child and adolescent providers.
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Affiliation(s)
- A Ning Zhou
- San Francisco Department of Public Health Behavioral Health Services and Primary Care Behavioral Health, 3850 17th Street, San Francisco, CA 94114, USA; University of California, San Francisco Department of Psychiatry and Behavioral Sciences, Box 3134, 675 18th Street, San Francisco, CA 94107, USA.
| | - Kai J Huang
- University of California, San Francisco School of Medicine, Program in Medical Education - Urban Underserved, 513 Parnassus Avenue, Suite S221, San Francisco, CA 94143, USA
| | - Terence L Howard
- University of California, San Francisco Department of Psychiatry and Behavioral Sciences, Box 3134, 675 18th Street, San Francisco, CA 94107, USA
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Miller VA, Miller C, Davis SM, Nokoff NJ, Buchanan C, Friedrich EA, Carl A, Strine S, Vogiatzi MG. Information needs and health status in adolescents and young adults with differences of sex development or sex chromosome aneuploidies. J Pediatr Urol 2023; 19:586-595. [PMID: 37308330 DOI: 10.1016/j.jpurol.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION When and how to provide condition-related information to adolescents and young adults (AYAs) with differences of sex development or sex chromosome aneuploidies (DSDs or SCAs) is largely based on anecdotal experience and lacks informed guidance. For AYAs with a DSD or SCA, having accurate information is critical for attaining optimal adjustment and well-being, participating in decision making related to treatment options, and transitioning successfully to adult health care, yet prior studies have focused exclusively on parental perspectives and not on the views of adolescents themselves. OBJECTIVE The objective of this study was to describe unmet information needs in AYAs with a DSD or SCA and examine associations with perceived global health. METHODS Participants were recruited from specialty clinics at Children's Hospital of Philadelphia (n = 20) and Children's Hospital Colorado (n = 60). AYAs ages 12-21 years with a DSD or SCA and a parent completed a survey assessing perceived information needs across 20 topics, importance of those topics, and global health using the PROMIS Pediatric Global Health questionnaire (PGH-7). RESULTS AYAs had diagnoses of Klinefelter syndrome (41%), Turner syndrome (25%), and DSD (26%) and were 16.7 years (SD = 2.56) and 44% female. Parent participants were primarily mothers (81%). AYAs perceived that 48.09% of their information needs were unmet (SD = 25.18, range: 0-100). Parents perceived that 55.31% of AYAs' information needs were unmet (SD = 27.46 range: 5-100). AYAs and parents across conditions reported unmet needs related to information about transition to adult health care, financial support for medical care, and how the condition might affect the AYA's health in the future. While AYA-reported PGH-7 scores were not associated with percentage of AYA unmet information needs, parent-reported PGH-7 scores were (r = -.46, p < .001), such that lower parent-reported global health was associated with higher percentage of AYA unmet information needs. DISCUSSION/CONCLUSION On average, parents and AYAs perceived that half of AYAs' information needs were unmet, and a higher percentage of AYA unmet information needs was associated with lower perceived global health. The frequency of unmet needs in this sample of AYAs reflects an opportunity for improvement in clinical care. Future research is needed to understand how education to children and AYAs unfolds as they mature and to develop strategies to address the information needs of AYAs with a DSD or SCA, promote well-being, and facilitate AYA engagement in their own health care.
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Affiliation(s)
- Victoria A Miller
- Division of Adolescent Medicine, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Christina Miller
- Graduate Program in Genetic Counseling, University of Colorado Anschutz Medical Campus, 13001 East 17th Place, W5107, Aurora, CO, 80045, USA
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Natalie J Nokoff
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Cindy Buchanan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Elizabeth A Friedrich
- Division of Adolescent Medicine, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Alexandra Carl
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Sophia Strine
- Division of Endocrinology and Diabetes, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Maria G Vogiatzi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Weidler EM, Suorsa-Johnson KI, Baskin AS, Fagerlin A, Gardner MD, Rutter MM, Schafer-Kalkhoff T, van Leeuwen K, Sandberg DE. "It became easier once I knew": Stakeholder perspectives for educating children and teenagers about their difference of sex development. Patient Educ Couns 2023; 113:107763. [PMID: 37087875 DOI: 10.1016/j.pec.2023.107763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/05/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Secrecy about a child's difference of sex development (DSD) can lead to internalized shame and stigma. We explored how teenagers and adults with DSD, parents, healthcare providers, and allied professionals value and perceive patient education. METHODS Stakeholders (n = 110) completed qualitative semi-structured interviews. Relevant themes for educational content were queried and organized. RESULTS Education was consistently identified as essential to successful outcomes. There was less consistency in how to educate patients. Disagreement existed regarding who should champion the education process. Participants believed medically relevant information should be shared gradually with attention to developmental capacity. Details were lacking regarding how much or what information to share. Participants noted that vetted resources were helpful. Benefits of sharing condition-specific information with patients included supporting their psychosocial development. Barriers included parental resistance to sharing information due to shame/stigma, and cultural and/or family dynamics. CONCLUSIONS Stakeholders' different perspectives regarding patient DSD education warrant future research to focus on the design, evaluation, and implementation of education-focused interventions. PRACTICE IMPLICATIONS Healthcare providers are responsible for supporting the education of children and teenagers with DSD about their condition. When considering barriers, adopting a cultural or family systems framework can reduce parental resistance and promote open dialogue.
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Affiliation(s)
- Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - Kristina I Suorsa-Johnson
- Division of Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA.
| | - Alison S Baskin
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA; Veterans Administration Health Services Research and Development Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, USA
| | - Melissa D Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Meilan M Rutter
- Accord Alliance, USA; Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - David E Sandberg
- Accord Alliance, USA; Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA; Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Peard LM, Morin J, Flores V, Graham K, Taylor AS, Pope JC, Halstead V, Cost NG, Roberts EM, Makari JH, Cranford W, Saltzman AF. Gonadal tumors in a contemporary cohort of patients with differences in sex development undergoing surgery - A multi-site study from the Pediatric Urologic Oncology Working Group of the societies for pediatric urology. J Pediatr Urol 2023:S1477-5131(23)00136-5. [PMID: 37117082 DOI: 10.1016/j.jpurol.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Disturbances in gonadal development lead to increased risk of gonadal malignancy in some but not all patients with differences in sex development (DSD). However, the natural history of these tumors is poorly described, and the literature remains sparse. OBJECTIVE The objective of this study was to describe the incidence of germ cell neoplasia in situ (GCNIS) and germ cell tumor (GCT) in a contemporary cohort of patients with DSD undergoing surgery and to provide long-term oncologic outcomes for these patients. STUDY DESIGN Patients with DSD who have undergone gonadectomy or gonadal biopsy were identified at four institutions. Clinical characteristics, pathology, and treatment details were obtained retrospectively. Patients were stratified into risk categories based on DSD diagnosis. Oncologic treatment and outcomes were recorded. Descriptive statistics are reported using parametric methods. RESULTS 83 patients were identified. Distribution of diagnoses is summarized in the summary table. 14 (16.9%) patients underwent gonadal biopsy, and 71 (85.5%) patients underwent gonadectomy (50/71 gonadectomies were bilateral). 8/83 (9.6%) patients had GCNIS or GCT (7 GCNIS, 1 GCT). Median age at surgery was 2.95 years (y) (interquartile range [IQR] 0.6-12.2) and 14y (IQR 0.85-16.9) in patients without and with GCNIS/GCT, respectively. All 8 patients with GCNIS/GCT had high or intermediate risk DSD diagnoses (4 mixed gonadal dysgenesis, 3 Turner with Y, 1 partial gonadal dysgenesis). Of the patients with high-risk diagnoses, 8/54 (15%) had GCNIS/GCT. No patient received adjuvant therapy, no patient had a recurrence, and all patients were living with mean follow up 6.4y. DISCUSSION The risk of gonadal malignancy is heterogeneous in the DSD population and can vary based on DSD diagnosis as well as maturation, testicularization, and location of the gonads. The most recent consensus recommendations on gonadal management emphasize risk stratification and consideration of gonadal surveillance based on gender of rearing, but supporting literature remains sparse. In this contemporary cohort of DSD patients who underwent gonadal surgery, most patients did not have evidence of adverse pathology, all patients with malignant or premalignant pathology had a high/intermediate risk DSD diagnosis, and all patients with GCNIS/GCT were treated with surgery alone without recurrence. CONCLUSIONS The distribution of patients with premalignant and malignant gonadal pathology and DSD in this cohort aligns with prior literature, and oncologic outcomes were excellent. These data add valuable information to the current literature and highlight the necessity to develop appropriate screening regimens for retained gonads.
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Affiliation(s)
- Leslie M Peard
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA; Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Jacqueline Morin
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Viktor Flores
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Kyle Graham
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Abby S Taylor
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - John C Pope
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Valeska Halstead
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Nicholas G Cost
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Evan M Roberts
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - John H Makari
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - Will Cranford
- Department of Biostatistics, College of Public Health, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Amanda F Saltzman
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
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Guaragna-Filho G, Guerra-Junior G, Tadokoro-Cuccaro R, Hughes IA, Barros BA, Hiort O, Balsamo A, Guran T, Holterhus PM, Hannema S, Poyrazoglu S, Darendeliler F, Bryce J, Ahmed SF, Quigley CA. Pubertal and Gonadal Outcomes in 46,XY Individuals with Partial Androgen Insensitivity Syndrome Raised as Girls. Sex Dev 2023; 17:16-25. [PMID: 36917969 DOI: 10.1159/000526997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 09/06/2022] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Although it was common in the 1970s-1990s to assign female gender of rearing to 46,XY infants with limited virilization of varying etiologies, including those with partial androgen insensitivity syndrome (PAIS), long-term data on outcomes for these individuals are sparse. Therefore, our goal was to use the power of an international registry to evaluate clinical features, surgical management, and pubertal data in patients with a molecularly confirmed diagnosis of PAIS who were born before 2008 and were raised as girls. METHODS The current study interrogated the International Disorders of Sex Development Registry for available data on management and pubertal outcomes in individuals with genetically confirmed PAIS who were raised as girls. RESULTS Among the 11 individuals who fulfilled the key criteria for inclusion, the external masculinization score (EMS) at presentation ranged from 2 to 6 (median 5); 7 girls underwent gonadectomy before the age of 9 years, whereas 4 underwent gonadectomy in the teenage years (≥ age 13). Clitoral enlargement at puberty was reported for 3 girls (27%) who presented initially at the time of puberty with intact gonads. In the 9 individuals (82%) for whom gonadal pathology data were provided, there was no evidence of germ cell tumor at median age of 8.1 years. All girls received estrogen replacement, and 8/11 had attained Tanner stage 4-5 breast development at the last assessment. CONCLUSION In general, although it appears that female assignment in PAIS is becoming uncommon, our data provide no evidence to support the practice of prophylactic prepubertal gonadectomy with respect to the risk of a germ cell tumor.
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Affiliation(s)
| | - Gil Guerra-Junior
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas, Campinas, Brazil
| | | | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Beatriz A Barros
- Interdisciplinary Group for Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas, Campinas, Brazil
| | - Olaf Hiort
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Tulay Guran
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Paul M Holterhus
- Department of Pediatrics, Pediatric Endocrinology and Diabetes, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Sabine Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
- Expertise Center DSD and Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sukran Poyrazoglu
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Feyza Darendeliler
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Jillian Bryce
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
| | - S Faisal Ahmed
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Charmian A Quigley
- Department of Endocrinology, Sydney Children's Hospital, Randwick, New South Wales, Australia
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Weidler EM, Gardner M, Suorsa-Johnson KI, Schafer-Kalkhoff T, Rutter MM, Sandberg DE, van Leeuwen K. Surgical Decision-Making for Individuals with Differences of Sex Development: Stakeholders' views. Front Urol 2023; 3:1092256. [PMID: 37920724 PMCID: PMC10621752 DOI: 10.3389/fruro.2023.1092256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Advocacy and human rights organizations have called for a moratorium on elective surgical procedures until the patient is able to fully participate in the decision-making process. Due to the controversial nature surrounding surgery in differences of sex development (DSD) care, we aimed to assess the factors that teens and adults with DSD, parents, healthcare providers and other allied professionals consider pertinent to complex surgical decisions in DSD. Methods Stakeholders (n=110) in DSD care participated in semi-structured interviews exploring features and potential determinants of successful healthcare outcomes. Audio-recordings were transcribed, coded, and analyzed using qualitative data software. Codes for "Process of Decision-Making" and "Successful Outcome-Surgery/Appearance/Function" were further searched using keywords "surgery," "procedure," and "timing." Results Several themes were identified: 1) The nature or type of the decision being made; 2) Who should be involved in the decision-making process; 3) Timing of conversations about surgery; 4) Barriers to decision-making surrounding surgery; 5) The elements of surgical decision-making; and 6) The optimal approach to surgical decision-making. Many stakeholders believed children and adolescents with DSD should be involved in the process as developmentally appropriate. Conclusion DSD include a wide range of diagnoses, some of which may require urogenital reconstruction to relieve obstruction, achieve continence, and/or address other anatomical differences whether cosmetic or functional. Adolescents and adults with DSD desired autonomy and to be part of the decision-making process. Parents were divided in their opinion of who should be involved in making elective surgical decisions: the child or parents as proxy medical decision-makers. Providers and other professionals stressed the importance of process and education around surgical decisions. Ongoing research examines how decision-makers evaluate tradeoffs associated with decision options.
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Affiliation(s)
- Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s, Phoenix, Arizona
- Accord Alliance, USA
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center and Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kristina I. Suorsa-Johnson
- Division of Pediatric Psychology and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meilan M. Rutter
- Accord Alliance, USA
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David E. Sandberg
- Accord Alliance, USA
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center and Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children’s, Phoenix, Arizona
- Accord Alliance, USA
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Amies Oelschlager AM. The Association between Surgeon Dissatisfaction with Infant Genital Appearance and Surgical Decision-Making Surrounding Clitoroplasty. J Pediatr Adolesc Gynecol 2023; 36:3-4. [PMID: 36336140 DOI: 10.1016/j.jpag.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
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Robevska G, Hanna C, van den Bergen J, Welch J, Couper J, Harris S, Joshi K, Brown J, Sabin M, Sinclair A, O'Connell M, Ayers K. Genetic Variants in SRD5A2 in a Spectrum of DSD Patients from Australian Clinics Highlight Importance of Genetic Testing alongside Typical First-Line Investigations. Sex Dev 2023; 17:8-15. [PMID: 36724755 DOI: 10.1159/000527754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Steroid 5-alpha reductase deficiency (5α-R2D) is a rare condition caused by genetic variants that reduce the activity of the enzyme that converts testosterone into dihydrotestosterone. The clinical spectrum of 5α-R2D is known to overlap with other 46,XY differences of sex development (DSD) such as androgen insensitivity or gonadal dysgenesis. However, the clinical trajectories of the aetiologies can differ, with 5α-R2D presenting its own challenges. METHODS In this study, we have collated clinical information for five individuals with variants in SRD5A2 identified using research genetic testing in an Australian paediatric setting. RESULTS We describe how a genetic finding resolved or confirmed a diagnosis for these individuals and how it guided clinical management and family counselling. CONCLUSION This work highlights the importance of early genetic testing in children born with 46,XY DSD where it complements traditional first-line testing.
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Affiliation(s)
- Gorjana Robevska
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Chloe Hanna
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | - John Welch
- Department of Paediatric Endocrinology and Diabetes, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Jennifer Couper
- Department of Diabetes and Endocrinology, Women's and Children's Hospital, Adelaide, South Australia, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Shannon Harris
- Department of Diabetes and Endocrinology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Kriti Joshi
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Justin Brown
- Department of Paediatric Endocrinology and Diabetes, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Matthew Sabin
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Sinclair
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Michele O'Connell
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Katie Ayers
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Suorsa-Johnson KI, Gardner MD, Brinkman W, Carley M, Gruppen L, Liang N, Lightfoot S, Pinkelman K, Speiser PW, VanderBrink B, Wisniewski J, Sandberg DE, Stacey D. A survey of healthcare professionals' perceptions of the decisional needs of parents with an infant born with a disorder/difference of sex development. J Pediatr Urol 2023; 19:39-49. [PMID: 36244898 PMCID: PMC10603597 DOI: 10.1016/j.jpurol.2022.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/05/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Parents of infants born with differences in sex development (DSD) face many difficult decisions. As part of a larger project designed to develop educational interventions to promote shared decision making, this study assessed healthcare professionals' (HCPs) perceptions of parental decision-making needs when an infant is born with a DSD. METHODS A cross-sectional web-based survey following the Ottawa Decision Support Framework was conducted in two waves, between October 2020 and June 2022. Survey domains included: common DSD decisions, indicators of parents' decisional needs, and resources and approaches to support parental decision making. Eligible participants were HCPs working within interprofessional pediatric DSD centers in the USA. Up to three reminders were sent. Descriptive analysis was conducted. RESULTS 71 HCPs participated; most (>90%) reported parents experience signs of decisional conflict including feeling unsure, worrying about what could go wrong, and fear of choosing a "wrong," irreversible option. The majority (90%) reported parents experience strong emotions interfering with their receptivity to information or deliberation. The majority (>70%) identified inadequate parental knowledge of the DSD as a barrier to decision making, coupled with information overload (>90%). HCPs rated several factors as "very" important, including: parents having information on benefits, harms, and other features of options (93%), having information about all the available options (87%), and having access to providers to discuss the options (84%). Providers endorsed using a variety of approaches to support parents' decision making; however, access to decision aids was not universally rated as highly important (very, 44%; somewhat, 46%; a little, 10%). IMPLICATIONS Overall, HCPs expressed favorable attitudes toward supporting active parental participation in medical decision making. Opportunities for enhanced support of shared decision making included: a) recognizing and addressing parental emotional distress and informational overload at a time when parents need to consider complex options for their infant or young child; and b) the need for HCPs to encourage values clarification in decision-making encounters with parents.
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Affiliation(s)
- Kristina I Suorsa-Johnson
- Department of Pediatrics, Division of Psychiatry and Behavioral Health, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT, USA
| | - Melissa D Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
| | - William Brinkman
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Larry Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | | - Phyllis W Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Brian VanderBrink
- Division of Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - David E Sandberg
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA; Department of Pediatrics, Division of Pediatric Psychology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Nursing, University of Ottawa, Ottawa, ON, Canada.
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Batista RL, Inácio M, Brito VN, Sircili MHP, Bag MJ, Gomes NL, Costa EMF, Domenice S, Mendonca BB. Sexuality and fertility desire in a large cohort of individuals with 46, XY differences in sex development. Clinics (Sao Paulo) 2023; 78:100185. [PMID: 36965237 PMCID: PMC10091460 DOI: 10.1016/j.clinsp.2023.100185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/31/2023] [Accepted: 03/02/2023] [Indexed: 03/27/2023] Open
Abstract
OBJECTIVE To analyze aspects of sexual life and fertility desire among 46, XY DSD people, including those who changed their gender. METHODS It is a cross-sectional study including 127 adults (> 16 years of age) with 46, XY DSD (83 females; 44 males) from a Single Brazilian Tertiary-Care Medical Center. RESULTS Sexual fantasies and masturbation were more frequent in 46, XY DSD males, whereas orgasm and sexual life satisfaction were similar in both genders. More 46, XY DSD men than women had a long-term romantic relationship. 46, XY DSD women with prenatal androgen exposure reported more fear of being romantically rejected. External genitalia appearance at birth did not impact the sexuality of 46, XY DSD women after surgical genital treatment had been completed. Overall, the sexual life was similar between 46, XY men assigned as males and those who changed to the male gender. Regarding sexual orientation, most self-reported as heterosexual (91% and 92% of women and men, respectively). The desire for fertility had a similar prevalence in both genders, but more women than men considered infertility a barrier to a long-term romantic relationship. Twelve individuals (7 males) had children; 10 out of 12 have adopted children. CONCLUSION Fertility desire was shared among 46, XY DSD people, regardless of gender. Prenatal androgen exposure reduced the desire for motherhood in 46, XY women. 46, XY DSD people who changed from female to male gender presented similar sexual parameters as those assigned as males. Among females, virilized genitalia at birth did not affect sexuality once the surgical treatment is completed.
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Affiliation(s)
- Rafael Loch Batista
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Marlene Inácio
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Vinicius Nahime Brito
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Helena Palma Sircili
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Min Jeong Bag
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nathália Lisboa Gomes
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Elaine Maria Frade Costa
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sorahia Domenice
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Berenice Bilharinho Mendonca
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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de Brouwer IJ, Suijkerbuijk M, van de Grift TC, Kreukels BPC. First Adolescent Romantic and Sexual Experiences in Individuals With Differences of Sex Development/Intersex Conditions. J Adolesc Health 2022; 71:688-695. [PMID: 36088232 DOI: 10.1016/j.jadohealth.2022.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Adolescence is an important period for sexual development, including sexual debut. The purpose of this study was to assess first romantic and sexual experiences and debut age in individuals with differences of sex development (DSD/intersex) and compare these with age-matched and gender-matched population control values. METHODS Questionnaire data on sociodemographic characteristics, romantic and sexual milestones (e.g., masturbation, dating), satisfaction with sexual life and sexual activity at follow-up, self-esteem, and feelings of femininity or masculinity were collected from 976 participants in Europe with a DSD condition. Participants were divided into six diagnostic subgroups based on their diagnostic classification: women with Turner syndrome, congenital adrenal hyperplasia, 46XY-DSD nonvirilized, and 46XY-DSD female partially virilized conditions and men with 46XY-DSD male or Klinefelter syndrome. Age-specific and gender-specific reference values were retrieved from a Dutch population sample. RESULTS Individuals with DSD were less likely to reach each of the romantic and sexual milestones compared to their peers without these conditions and they were significantly older when reaching these milestones. Between clinical subgroups, individuals with Klinefelter were significantly older when reaching milestones and in the female groups and individuals with Turner were the least likely to reach milestones. Furthermore, a higher age when reaching several romantic and sexual milestones was correlated with lower self-esteem, lower satisfaction with sexual life, and lower sexual frequency at follow-up. DISCUSSION Due to a difference in biopsychosocial context, individuals with DSD often experience a different and/or delayed sexual development during adolescence. Healthcare providers should be aware of these differences in adolescents with DSD and their sexual development to optimize affirmative counseling.
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Affiliation(s)
- Iris J de Brouwer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Department of Medical Psychology, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Merel Suijkerbuijk
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Amsterdam University Medical Center (location VUmc), Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
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Szymanski KM, Kokorowski P, Braga LH, Frady H, Whittam B, Hensel DJ; Life with Congenital Adrenal Hyperplasia Study Group. Growing up with clitoromegaly: experiences of North American women with congenital adrenal hyperplasia. J Pediatr Urol 2022; 18:775-83. [PMID: 35752554 DOI: 10.1016/j.jpurol.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/25/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION To describe experiences of clitoromegaly in women with congenital adrenal hyperplasia (CAH). METHODS CAH females (46XX, ≥16 years old) from the United States and Canada were eligible for a cross-sectional online survey (2019-2020) if reporting clitoromegaly (life-long: "growing up with a larger than average clitoris," secondary: "clitoris grew over weeks or months"). A multidisciplinary team and women with CAH drafted questions assessing net effects of clitoromegaly on 10 activities and 10 life domains. Fisher's exact test was used to compare net effect (positive-negative) vs. no effect (Bonferroni p = 0.05/10 = 0.005). RESULTS Of 97 women with CAH enrolled, 53 women (55%, median age: 36 years, advocacy group recruitment: 81%) reported recognizing clitoromegaly at median 11-13 years old, with 21% identifying it in adulthood. There was no difference in self-reported timing or clitoral shape between life-long or secondary clitoromegaly (p ≥ 0.06). There were no net positive effects of clitoromegaly. Rather, clitoromegaly had net negative effects on 7/10 activities (p ≤ 0.003) and no net effect (neutral) on 3 (Table). Women were less likely to wear tight clothing, change clothes in public locker rooms and play group sports. Women reported net negative effects for most romantic activities (dating, any sexual activity, pain-free sexual activity, having a partner see their genitalia, p=<0.003), but did not report a net effect on pleasurable sexual activity (p = 0.12). Clitoromegaly had net negative effects in 9/10 life domains (p < 0.001) and neutral on job self-perception (p = 0.25). Few women reported any positive impact (2-6%). However, 49-59% of women experienced poor self-esteem, anxiety, gender self-perception and body image, while 36% felt "down or depressed." Also, 21-23% experienced negative self-perception as friends and parents, 42-47% reported negative effects on plans for romantic and sexual relationships. Responses did not differ with advocacy group membership (p ≥ 0.02). DISCUSSION Our findings support qualitative and case series evidence that clitoromegaly has a negative psychological outcome on women with CAH. Clitoromegaly may add to the burden of living with a chronic endocrine disease. Women with positive and negative experiences had the same opportunity to participate. Since we could not assess objective clitoral size, baseline virilization and exact nature of any childhood clitoral procedures, these data cannot be used to estimate the impact of specific clitoral size or effectiveness of early clitoral treatments. CONCLUSIONS Clitoromegaly appears to be common among women with CAH. While experiences of clitoromegaly vary between women, the overall experience is negative in multiple social, romantic, and emotional activities and domains.
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Suorsa-Johnson KI, Gardner MD, Baskin A, Gruppen LD, Rose A, Rutter MM, Schafer-Kalkhoff T, Stacey D, van Leeuwen KD, Weidler EM, Sandberg DE. Defining successful outcomes and preferences for clinical management in differences/disorders of sex development: Protocol overview and a qualitative phenomenological study of stakeholders' perspectives. J Pediatr Urol 2022; 18:36.e1-36.e17. [PMID: 34876378 PMCID: PMC8983568 DOI: 10.1016/j.jpurol.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/25/2021] [Accepted: 10/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Utilizing a qualitative phenomenological design, the Defining Successful Outcomes and Trade-offs study examined stakeholder perspectives regarding optimal healthcare delivery and outcomes for individuals with a difference/disorder of sex development (DSD). OBJECTIVE We describe study methods and provide an overview of themes and subthemes. STUDY DESIGN Interviews were conducted with individuals with a DSD (n = 24), parents of those with a DSD (n = 19), healthcare providers (n = 37), and others (n = 30). Primary questions regarding clinical management of patients with DSD were: "What is a successful outcome?" and "How do you achieve it?" RESULTS Themes included: understanding of DSD diagnosis and self-efficacy in management is necessary but complex; patient and family psychological well-being; support from others versus being stigmatized; affected person experiences physical health and accepts the implications of their condition; complexities in DSD decision making, roles and expectations; and knowledgeable providers and multidisciplinary teams are essential, notwithstanding persisting barriers. Participants recognized competing values potentially forcing trade-offs in decision making. DISCUSSION Recognition of diverse and sometimes conflicting perspectives regarding optimal pathways of care and outcomes - both within and among those with DSD and their providers -promises to enhance shared decision making. CONCLUSION Diverse perspectives and perceptions of trade-offs associated with DSD healthcare emphasize the need to tailor care for patients and families.
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Affiliation(s)
- Kristina I Suorsa-Johnson
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Melissa D Gardner
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Alison Baskin
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA
| | - Larry D Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - Angela Rose
- Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA
| | - Meilan M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA; Accord Alliance, USA
| | - Tara Schafer-Kalkhoff
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Dawn Stacey
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; School of Nursing, University of Ottawa, Ottawa, Canada
| | - Kathleen D van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, USA; Accord Alliance, USA
| | - David E Sandberg
- Department of Pediatrics, University of Michigan Medical School, Division of Pediatric Psychology, Ann Arbor, USA; Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, USA; Accord Alliance, USA.
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Mönig I, Schneidewind J, Johannsen TH, Juul A, Werner R, Lünstedt R, Birnbaum W, Marshall L, Wünsch L, Hiort O. Pubertal development in 46,XY patients with NR5A1 mutations. Endocrine 2022; 75:601-613. [PMID: 34613524 PMCID: PMC8816419 DOI: 10.1007/s12020-021-02883-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Mutations in the NR5A1 gene, encoding the transcription factor Steroidogenic Factor-1, are associated with a highly variable genital phenotype in patients with 46,XY differences of sex development (DSD). Our objective was to analyse the pubertal development in 46,XY patients with NR5A1 mutations by the evaluation of longitudinal clinical and hormonal data at pubertal age. METHODS We retrospectively studied a cohort of 10 46,XY patients with a verified NR5A1 mutation and describe clinical features including the external and internal genitalia, testicular volumes, Tanner stages and serum concentrations of LH, FSH, testosterone, AMH, and inhibin B during pubertal transition. RESULTS Patients who first presented in early infancy due to ambiguous genitalia showed spontaneous virilization at pubertal age accompanied by a significant testosterone production despite the decreased gonadal volume. Patients with apparently female external genitalia at birth presented later in life at pubertal age either with signs of virilization and/or absence of female puberty. Testosterone levels were highly variable in this group. In all patients, gonadotropins were constantly in the upper reference range or elevated. Neither the extent of virilization at birth nor the presence of Müllerian structures reliably correlated with the degree of virilization during puberty. CONCLUSION Patients with NR5A1 mutations regardless of phenotype at birth may demonstrate considerable virilization at puberty. Therefore, it is important to consider sex assignment carefully and avoid irreversible procedures during infancy.
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Affiliation(s)
- Isabel Mönig
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany.
| | - Julia Schneidewind
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Trine H Johannsen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
- Institute for Molecular Medicine, University of Lübeck, Lübeck, Germany
| | - Ralf Lünstedt
- Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
| | - Wiebke Birnbaum
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Louise Marshall
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Lutz Wünsch
- Department of Paediatric Surgery, University of Lübeck, Lübeck, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Lübeck, Germany
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19
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Rowell EE, Lautz TB, Lai K, Weidler EM, Johnson EK, Finlayson C, van Leeuwen K. The ethics of offering fertility preservation to pediatric patients: A case-based discussion of barriers for clinicians to consider. Semin Pediatr Surg 2021; 30:151095. [PMID: 34635275 DOI: 10.1016/j.sempedsurg.2021.151095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Decisions about fertility preservation can be difficult in general but the recent application of preservation techniques to pediatric patients has ushered in a host of new ethical considerations. Fertility preservation (FP) may be considered for all patients who are at risk for infertility due to their medical diagnosis or treatment, including those undergoing gonadotoxic chemotherapy, those with differences of sex development (DSD) undergoing gonadectomy,1-3 and transgender patients undergoing gender affirming surgery. The focus of this paper is to review the ethical issues involved in offering FP to pediatric oncology patients and, to a lesser extent, the new ethical issues that apply to patients with DSD. Some of the techniques and approach to counseling will also apply to transgender individuals, although that is beyond the scope of this work. We aim to discuss several barriers to offering FP and to advise how to counsel families in the setting of rapid changes in this field. Families should be educated about:Specific guidance for clinicians regarding some of these points was recently published in an American Academy of Pediatrics Clinical Report,1 and we will illustrate the use of these guidelines in four case presentations.
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20
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Kouri C, Sommer G, Flück CE. Oligogenic Causes of Human Differences of Sex Development: Facing the Challenge of Genetic Complexity. Horm Res Paediatr 2021; 96:169-179. [PMID: 34537773 DOI: 10.1159/000519691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Deviations of intrauterine sex determination and differentiation and postnatal sex development can result in a very heterogeneous group of differences of sex development (DSD) with a broad spectrum of phenotypes. Variants in genes involved in sexual development cause different types of DSD, but predicting the phenotype from an individual's genotype and vice versa remains challenging. SUMMARY Next Generation Sequencing (NGS) studies suggested that oligogenic inheritance contributes to the broad manifestation of DSD phenotypes. This review will focus on possible oligogenic inheritance in DSD identified by NGS studies with a special emphasis on NR5A1variants as an example of oligogenic origin associated with a broad range of DSD phenotypes. We thoroughly searched the literature for evidence regarding oligogenic inheritance in DSD diagnosis with NGS technology and describe the challenges to interpret contribution of these genes to DSD phenotypic variability and pathogenicity. Key Messages: Variants in common DSD genes like androgen receptor (AR), mitogen-activated protein kinase kinase kinase 1 (MAP3K1), Hydroxy-Delta-5-Steroid Dehydrogenase 3 Beta- And Steroid Delta-Isomerase 2 (HSD3B2), GATA Binding Protein 4 (GATA4), zinc finger protein friend of GATA family member 2 (ZFPM2), 17b-hydroxysteroid dehydrogenase type 3 (HSD17B3), mastermind-like domain-containing protein 1 (MAMLD1), and nuclear receptor subfamily 5 group A member 1 (NR5A1) have been detected in combination with additional variants in related genes in DSD patients with a broad range of phenotypes, implying a role of oligogenic inheritance in DSD, while still awaiting proof. Use of NGS approach for genetic diagnosis of DSD patients can reveal more complex genetic traits supporting the concept of oligogenic cause of DSD. However, assessing the pathomechanistic contribution of multiple gene variants on a DSD phenotype remains an unsolved conundrum.
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Affiliation(s)
- Chrysanthi Kouri
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Grit Sommer
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland
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21
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Leitao Braga B, Lisboa Gomes N, Nishi MY, Freire BL, Batista RL, D Faria Junior JA, Funari MFA, Figueredo Benedetti AF, de Moraes Narcizo A, Cavalca Cardoso L, Lerario AM, Guerra-Junior G, Frade Costa EM, Domenice S, Jorge AAL, Mendonca BB. Variants in 46,XY DSD-Related Genes in Syndromic and Non-Syndromic Small for Gestational Age Children with Hypospadias. Sex Dev 2021; 16:27-33. [PMID: 34518484 DOI: 10.1159/000518091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/28/2020] [Accepted: 06/23/2021] [Indexed: 11/19/2022] Open
Abstract
Hypospadias is a common congenital disorder of male genital formation. Children born small for gestational age (SGA) present a high frequency of hypospadias of undetermined etiology. No previous study investigated the molecular etiology of hypospadias in boys born SGA using massively parallel sequencing. Our objective is to report the genetic findings of a cohort of patients born SGA with medium or proximal hypospadias. We identified 46 individuals with this phenotype from a large cohort of 46,XY DSD patients, including 5 individuals with syndromic features. DNA samples from subjects were studied by either whole exome sequencing or target gene panel approach. Three of the syndromic patients have 5 main clinical features of Silver-Russell syndrome (SRS) and were first studied by MLPA. Among the syndromic patients, loss of DNA methylation at the imprinting control region H19/IGF2 was identified in 2 individuals with SRS clinical diagnosis. Two novel pathogenic variants in compound heterozygous state were identified in the CUL7 gene establishing the diagnosis of 3M syndrome in one patient, and a novel homozygous variant in TRIM37 was identified in another boy with Mulibrey nanism phenotype. Among the non-syndromic subjects, 7 rare heterozygous variants were identified in 6 DSD-related genes. However, none of the variants found can explain the phenotype by themselves. In conclusion, a genetic defect that clarifies the etiology of hypospadias was not found in most of the non-syndromic SGA children, supporting the hypothesis that multifactorial causes, new genes, and/or unidentified epigenetic defects may have an influence in this condition.
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Affiliation(s)
- Barbara Leitao Braga
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Nathalia Lisboa Gomes
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Mirian Y Nishi
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Bruna L Freire
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Rafael L Batista
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Jose A D Faria Junior
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Mariana F A Funari
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Anna F Figueredo Benedetti
- Laboratorio de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Amanda de Moraes Narcizo
- Laboratorio de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Lais Cavalca Cardoso
- Laboratorio de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | - Elaine M Frade Costa
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Sorahia Domenice
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
| | - Alexander A L Jorge
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil.,Unidade de Endocrinologia Genetica, Laboratorio de Endocrinologia Celular e Molecular LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento - LIM/42, Hospital das Clinicas, Disciplina de Endocrinologia da FMUSP, Sao Paulo, Brazil
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22
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Pachernegg S, Georges E, Ayers K. The Desert Hedgehog Signalling Pathway in Human Gonadal Development and Differences of Sex Development. Sex Dev 2021; 16:98-111. [PMID: 34518472 DOI: 10.1159/000518308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/02/2021] [Accepted: 05/31/2021] [Indexed: 11/19/2022] Open
Abstract
While the Hedgehog signalling pathway is implicated in numerous developmental processes and maladies, variants in the Desert Hedgehog (DHH) ligand underlie a condition characterised by 46,XY gonadal dysgenesis with or without peripheral neuropathy. We discuss here the role and regulation of DHH and its signalling pathway in the developing gonads and examine the current understanding of how disruption to this pathway causes this difference of sex development (DSD) in humans.
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Affiliation(s)
- Svenja Pachernegg
- Reproductive Development Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Georges
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Katie Ayers
- Reproductive Development Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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23
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Knoll MM, Strickland J, Jacobson JD. Can Boys Have Turner Syndrome? More than a Question of Semantics. Sex Dev 2021; 16:19-26. [PMID: 34515231 DOI: 10.1159/000518092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/24/2021] [Accepted: 06/23/2021] [Indexed: 11/19/2022] Open
Abstract
Individuals with 45,X mosaicism with Y chromosome material raised as boys are not diagnosed with Turner syndrome, a label restricted to phenotypic females. We sought to determine if boys with 45,X mosaicism had features consistent with Turner syndrome. Twenty-two patients (14 girls, 8 boys) seen in our Differences of Sex Development (DSD) clinic were identified for review. Standardized height (z-scores) by sex of rearing and results of cardiology, renal, audiology, thyroid, and celiac screenings were recorded. All subjects had heights below the mean for sex. Z-scores were not significantly different between boys and girls (p = 0.185). There were no significant differences in the incidence of cardiac anomalies between boys and girls (p = 0.08). Girls were more likely to have additional screenings (p = 0.042), but there were no significant differences in the number of positive screenings between boys and girls (p = 0.332). Patients with 45,X mosaicism raised as boys appear to have features similar to patients with the same karyotype raised as girls. Routine screening of boys following the Turner Syndrome Clinical Practice Guidelines may allow early recognition of comorbidities. Additionally, obtaining karyotypes on boys with short stature or other features of Turner syndrome may identify unrecognized cases of 45,X mosaicism.
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Affiliation(s)
- Michelle M Knoll
- Division of Endocrinology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Julie Strickland
- Division of Gynecology, Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jill D Jacobson
- Division of Endocrinology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
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24
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Bangalore Krishna K, Kogan BA, Mazur T, Hoebeke P, Bogaert G, Lee PA. Individualized care for patients with intersex ( differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery. J Pediatr Urol 2021; 17:338-345. [PMID: 33691983 DOI: 10.1016/j.jpurol.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.
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Affiliation(s)
| | | | | | | | - Guy Bogaert
- University Hospital, UZLeuven, Leuven, Belgium
| | - Peter A Lee
- Penn State College of Medicine, Hershey, PA, 17033, USA
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25
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Szymanski KM, Rink RC, Whittam B, Hensel DJ. Majority of females with a life-long experience of CAH and parents do not consider females with CAH to be intersex. J Pediatr Urol 2021; 17:210.e1-210.e9. [PMID: 33041207 DOI: 10.1016/j.jpurol.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/04/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION To assess opinions of females with CAH, and parents of females with CAH, about designating this population "intersex," particularly in legislation about genital surgery during childhood. METHODS We conducted a mixed-methods (quantitative and qualitative) anonymous cross-sectional online survey of females with CAH (46XX, 16+years old) and independently recruited parents of girls with CAH (2019-2020) diagnosed in first year of life from the United States. A multidisciplinary CAH team drafted the survey in collaboration with women with CAH and parents. Fisher's exact test was used to compare female and parent responses. A qualitative thematic approach was used to analyze open-ended answers for emergent categories of reasons why CAH females should or should not be considered as intersex. RESULTS Of 57 females with CAH participating (median age: 39 years, 75.5% of ≥25year olds had post-secondary degree), all had classical CAH and 93.0% underwent genital surgery at median 1-2 years old. While 89.5% did not endorse the intersex designation for CAH, the remaining 5.3% did (5.3% provided no answer, Summary Figure). Most CAH females (63.2%) believed CAH females should be considered separately in "any laws banning or allowing surgery of children's genitals" (19.3% disagreed, 17.5% neutral, 0.0% no answer). Most common themes identified by females with CAH not endorsing an intersex designation were: normal female internal organs, sex chromosomes, personal identity, genital appearance, issues with language, hormones, and those endorsing it: genital appearance, community/group experiences, topic complexity. Overall, 132 parents of females with CAH participated (parent/child median ages: 40/11 years, 81.7% of ≥25year olds had post-secondary degree). All children had classical CAH and 78.8% underwent surgery at median <1 year old. While 95.5% of parents did not endorse the intersex designation for CAH, 2.3% did (2.3% no answer), similar to females (p = 0.29). Most parents (81.1%) believed CAH females should be considered separately in legislation (9.1% disagreed, 6.1% neutral, 3.8% no answer), a slightly higher percentage than females (p = 0.01). DISCUSSION Echoing previously published disagreement with clinically designating CAH females as intersex, majority of CAH females and parents oppose a legal intersex designation. Differing opinions among females and parents strengthen concern about a one-size-fits-all approach to legislation about childhood genital surgery. Differences in opinions between female and parent responses, while statistically significant, were relatively small. CONCLUSION Majority of females with CAH and parents believe CAH should be excluded from the intersex designation, and should be considered separately in legislation pertaining to childhood genital surgery.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA.
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Devon J Hensel
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine and Department of Sociology, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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26
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Jürgensen M, Rapp M, Döhnert U, Frielitz FS, Ahmed F, Cools M, Thyen U, Hiort O. Assessing the health-related management of people with differences of sex development. Endocrine 2021; 71:675-680. [PMID: 33515437 PMCID: PMC8016813 DOI: 10.1007/s12020-021-02627-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/09/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Health care requirements and perception of people with differences of sex development (DSD) have changed enormously since the "Chicago Consensus Conference" in 2005. Therefore, new standards of care and evaluation of care have to be developed. METHODS We summarize the social and legal approach to care for DSD during the last two decades and report the main results of European research activities. RESULTS The last two decades were accompanied by legal and societal discussion regarding how to deal with a nonbinary concept of sex. This leads to the necessity to assess health care requirements for individuals with DSD in an objective manner. We briefly review the results of the recently funded European research projects dealing with health-related issues in DSD like EU COST Action DSD, I-DSD, and dsd-LIFE, and address the compilation of quality indicators that will be needed to benchmark health care provision and health care-related outcomes. CONCLUSIONS The benchmarking process has to be implemented among health care providers for individuals with DSD within the European Reference Networks for Rare Conditions.
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Affiliation(s)
- Martina Jürgensen
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Marion Rapp
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Ulla Döhnert
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Fabian-Simon Frielitz
- Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Faisal Ahmed
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Department of Medicine, Division of Endocrinology and Centre for Endocrine Tumors, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine Cools
- Division of Paediatric Endocrinology, Department of Paediatrics and Internal Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Ute Thyen
- Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany.
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27
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Cocchetti C, Ristori J, Mazzoli F, Prunas A, Bertelloni S, Magini A, Vignozzi L, Maggi M, Fisher AD. 5α-Reductase-2 deficiency: is gender assignment recommended in infancy? Two case-reports and review of the literature. J Endocrinol Invest 2020; 43:1131-1136. [PMID: 32036582 DOI: 10.1007/s40618-020-01193-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Gender assignment represents one of the most controversial aspects of the clinical management of individuals with Differences of Sex Development, including 5α-Reductase-2 deficiency (SRD5A2). Given the predominant female appearance of external genitalia in individuals with SRD5A2 deficiency, most of them were assigned to the female sex at birth. However, in the last years the high rate of gender role shift from female to male led to recommend a male gender assignment. METHODS We here describe two cases of subjects with SRD5A2 deficiency assigned as females at birth, reporting their clinical histories and psychometric evaluations (Body Uneasiness Test, Utrecht Gender Dysphoria Scale, Bem Sex-Role Inventory, Female Sexual Distress Scale Revised, visual analogue scale for gender identity and sexual orientation) performed at the time of referral at the Florence Gender Clinic. RESULTS Both patients underwent early surgical interventions without being included in the decision-making process. They had to conform to a binary feminine gender role because of social/familiar pressure, with a significant impact on their psychological well-being. Psychometric evaluations identified clinically significant body uneasiness and gender incongruence in both subjects. No sexually related distress and undifferentiated gender role resulted in the first subject and sexually related distress and androgynous gender role resulted in the second subject. CONCLUSIONS The reported cases suggest the possibility to consider a new approach for gender assignment in these individuals, involving them directly in the decision-making process and allowing them to explore their gender identity, also with the help of GnRH analogues to delay pubertal modifications.
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Affiliation(s)
- C Cocchetti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy
| | - J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy
| | - F Mazzoli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy
| | - A Prunas
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - S Bertelloni
- Pediatric Division, Department of Obstetrics, Gynecology and Pediatrics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - A Magini
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, University of Florence, Florence, Italy.
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28
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Alkazemi MH, Johnston AW, Meglin D, Adkins D, Routh JC. Community perspectives on difference of sex development (DSD) diagnoses: A crowdsourced survey. J Pediatr Urol 2020; 16:384.e1-384.e8. [PMID: 32409277 PMCID: PMC7308206 DOI: 10.1016/j.jpurol.2020.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/27/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES Differences of sex development (DSD) engender ethical, social and psychosexual complexities that can complicate medical decision-making. We performed a web-based pilot study to estimate the utility value of a DSD diagnosis and to identify community concerns regarding DSD management. METHODS A cross-sectional survey was posted on Amazon's Mechanical Turk, an online crowdsourcing platform. Respondents were ≥18y and were randomized to receive information on one of three common DSD conditions: Congenital Adrenal Hyperplasia (CAH), Mixed Gonadal Dysgenesis (MGD), and Partial Androgen Insensitivity Syndrome (PAIS). Time trade-off methodology was used to estimate utility values. Likert scale and statement-ranking questions were used to assess respondent perceptions. RESULTS Of 1,628 respondents, median age was 34y; most respondents were parents (59.1%), white (77.1%), and previously unfamiliar with DSD (60.4%). The median overall utility value was 0.70 (IQR 0.50-0.90), similar to moderately severe chronic health conditions. Utility estimates varied based on the DSD scenario presented (0.80 CAH vs. 0.70 MGD vs. 0.80 PAIS, p = 0.0006), respondent gender (p < 0.0001), race (p = 0.002), religion (p = 0.005), and prior knowledge of DSD (p < 0.0001). Reported concerns included gender identity (23.4%), urinary function (20.5%) and surgical complications (17.4%). Most (67.5%) supported early surgical intervention at 6-18 mo; 10.4% thought surgery should occur ≥18 y. COMMENT Limitations of this study include that survey participants were aware of the nature of the study, thus some respondents may have participated to skew the results. Given the nature of this pilot study, the representation of families with children with DSD within the study is severely limited given the rarity of DSDs. This means that their opinions may be diluted by the large sample size. However, because utility values are classically estimated according to community opinions, the utility data presented should be taken to reflect that of the specific sample studied and is not reflective of that of families with a vested interest in such cases. CONCLUSIONS Community-based respondents perceived that DSD conditions were associated with a reduction in utility values (0.70-0.80), on par with moderately severe chronic health conditions. Estimates varied based on respondents' gender, race, religion and prior knowledge of DSD. Gender identity was the most concerning aspect for respondents.
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Affiliation(s)
| | - Ashley W Johnston
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Diane Meglin
- Duke University School of Medicine, Durham, NC, USA
| | - Deanna Adkins
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan C Routh
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Wolffenbuttel KP, Holmdahl G. Perineal hypospadias repair with preservation of a coincidental vagina or perineal utricle in boys with disorders of sex development. J Pediatr Urol 2019; 15:626.e1-626.e5. [PMID: 31582336 DOI: 10.1016/j.jpurol.2019.09.002] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 09/02/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION An enlarged utricle in patients with proximal hypospadias or disorders of sex development (DSD) is common. The utricle orifice is usually in the posterior urethra near the verumontanum, but in exceptional cases located on the perineum. Concurrence of a perineal hypospadias and perineal utricle or vagina is also known as male vagina, pseudovagina, or blind vaginal pouch. The utricle in such cases is usually excised either before or concomitant with hypospadias repair. The authors developed an alternative approach in which the vagina or perineal utricle is retained during hypospadias repair and report on the results in four patients. OBJECTIVE To report a novel technique for perineal hypospadias repair while retaining a concurrent vagina or perineal utricle. PATIENTS AND METHODS Between 1999 and 2014, four neonates presented with perineal hypospadias. In all patients, a second perineal opening providing access to either an enlarged utricle or a vagina was identified. Karyotype in peripheral blood was in two patients 46,XY and in the other two 45,X/46,XY of which one showed a complex mosaicism in gonadal tissue. No genetic cause was identified on DNA evaluation in the two patients with 46,XY DSD. All patients were raised as boys. Hypospadias repair was performed in two stages at prepubertal age. During the second stage of surgery, performed between the age of 1.5 and 5 years, the vagina or utricle orifice was incorporated into the neo-urethra, resulting in a retained 'built-in' vagina or utricle. RESULTS Surgical procedures were uneventful, and patients remained asymptomatic during a mean postoperative follow-up of 8.5 (range 2-13.5) years. One patient was lost to follow-up after the age of 8 years. At their last visit, the remaining patients, at the age of 4, 15, and 17 years, were able to void in standing position without dribbling. Both adolescent patients reported erections without ejaculations and identified themselves as males without signs of gender dysphoria. CONCLUSION Hypospadias repair in boys with perineal hypospadias while leaving a male vagina or perineal utricle in situ has not been reported previously, and the study's preliminary results are favorable. One of the benefits of this approach is that inadvertent injury to adjacent anatomic structures such as urethral sphincter, neurovascular bundles, ureters, vas deferens, and rectum is avoided. The main rationale for adopting this conservative approach however is to minimize genital tissue removal in children with a not yet definite gender identity, which will certainly facilitate unforeseen future gender reassignment surgery.
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Affiliation(s)
- Katja P Wolffenbuttel
- Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Department of Urology and Paediatric Urology, Rotterdam, the Netherlands.
| | - Gundela Holmdahl
- Sahlgrenska Academy, Women's and Children's Health, Gothenburg, Sweden; Queen Silvia's Children's Hospital, Department of Paediatric Surgery, Gothenburg, Sweden
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Abstract
Differences of sex development (DSD) include a variety of complex congenital genitourinary abnormalities-whether sporadic or hereditary. The 2006 DSD Consensus Statement and 2016 Update Consensus Statement encourage better communication among providers, between providers and parents, as well as among providers, parents, and patients when developmentally appropriate.1,2 However, a lack of clear communication about the diagnosis and its sequelae may occur at three levels: (1) disclosure from DSD patients' families to their physician, (2) disclosure from patients to their families/communities, and (3) disclosure from the physician to the DSD patient. Additionally, there is a paucity of research available on how culture can impact disclosure among individuals with DSDs. This article discusses disclosure among the various stakeholders and briefly explores the impact of cultural expectations and beliefs with regards to disclosure.
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Affiliation(s)
- Erica M. Weidler
- Corresponding author: Address, Phoenix Children’s Hospital, 1919 E. Thomas Rd., Phoenix, Arizona 85016,
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Crerand CE, Kapa HM, Litteral JL, Nahata L, Combs B, Indyk JA, Jayanthi VR, Chan YM, Tishelman AC, Hansen-Moore J. Parent perceptions of psychosocial care for children with differences of sex development. J Pediatr Urol 2019; 15:522.e1-522.e8. [PMID: 31353277 DOI: 10.1016/j.jpurol.2019.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/27/2019] [Indexed: 11/19/2022]
Abstract
SHORT INTRODUCTION/BACKGROUND Children affected by differences/disorders of sex development (DSDs) and their families are vulnerable to significant risks across developmental stages that threaten quality of life and psychosocial functioning. Accordingly, both experts in DSD treatment and patient advocacy groups have endorsed the incorporation of psychosocial care into interdisciplinary management of DSD conditions. OBJECTIVE This study assessed psychosocial needs and received services reported by parents of children with DSD treated at two large US academic medical centers. Specifically, differences in parents' perceptions of psychosocial service needs were compared between those who received or did not receive interdisciplinary care that included psychology/social work professionals. STUDY DESIGN In a cross-sectional study, sixty-four parents of children with DSD aged 0-19 years attending two major academic centers with interdisciplinary teams completed a questionnaire about their receipt and perception of 12 individual psychosocial services throughout their child's DSD treatment. RESULTS Receipt of individual psychosocial services ranged from 27 to 81%. Most commonly, parents reported having a psychosocial provider explain medical terms and answer questions after talking with a doctor (81%), assist with words and terms to describe the condition and treatment (69%), and help navigate the hospital system (63%). Families positively endorsed psychosocial services, with 91-100% of services received rated as helpful. Parents of children who received care as part of an interdisciplinary team were significantly more likely to receive psychosocial services than those treated by single providers (e.g., urologists). Specific gaps in psychosocial care were noted in regard to access to mental health providers familiar with DSD, fertility counseling, and support with community advocacy (e.g., arranging for accommodations at the school or advocating on patient's behalf with the insurance company). Among families who had not received them, services most desired were assistance with words and terms to describe condition or treatment; explanation of medical terms and answering questions after meeting with a doctor; connection to resources such as books, pamphlets, websites, and support groups; and a central care coordinator for the medical team. DISCUSSION AND CONCLUSION Families value psychosocial services but are far less likely to receive services if they are not seen in an interdisciplinary clinic visit that includes a psychosocial provider. Families desire but often lack mental health, advocacy, and fertility-related support. This study highlights the need for sustained psychosocial follow-up across development, even in the absence of pressing medical concerns, to provide support and anticipatory guidance as needs and issues evolve.
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Affiliation(s)
- C E Crerand
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Plastic Surgery, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH 43210, USA.
| | - H M Kapa
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - J L Litteral
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - L Nahata
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - B Combs
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - J A Indyk
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - V R Jayanthi
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Urology, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Y-M Chan
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - A C Tishelman
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - J Hansen-Moore
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH 43210, USA
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Rogol AD, Pieper LP. The Interconnected Histories of Endocrinology and Eligibility in Women's Sport. Horm Res Paediatr 2019; 90:213-220. [PMID: 30336491 DOI: 10.1159/000493646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022] Open
Abstract
This report illustrates the links between history, sport, endocrinology, and genetics to show the ways in which historical context is key to understanding the current conversations and controversies about who may compete in the female category in elite sport. The International Association of Athletics Federations (IAAF) introduced hyperandrogenemia regulations for women's competitions in 2011, followed by the International Olympic Committee (IOC) for the 2012 Olympics. The policies concern female athletes who naturally produce higher-than-average levels of testosterone and want to compete in the women's category. Hyperandrogenemia guidelines are the current effort in a long series of attempts to determine women's eligibility scientifically. Scientific endeavors to control who may participate as a woman illustrate the impossibility of neatly classifying competitors by sex and discriminate against women with differences of sex development (also called intersex by some).
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Affiliation(s)
- Alan D Rogol
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Lindsay Parks Pieper
- Department of Sport Management, University of Lynchburg College, Lynchburg, Virginia,
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Heeley JM, Hollander AS, Austin PF, Merritt DF, Wesevich VG, Amarillo IE. Risk association of congenital anomalies in patients with ambiguous genitalia: A 22-year single-center experience. J Pediatr Urol 2018; 14:153.e1-153.e7. [PMID: 29157626 DOI: 10.1016/j.jpurol.2017.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 09/22/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ambiguous genitalia refers to a form of differences of sex development (DSD) wherein the appearance of the external genitalia is atypical. This rare condition presents challenges in decision-making and clinical management. Review of historical data may reveal areas for clinical research to improve care for patients with ambiguous genitalia. OBJECTIVE This chart review was performed to identify patients with ambiguous genitalia, and to classify them as having 46,XX DSD, 46,XY DSD, or sex chromosome DSD. Within these categories, we looked at establishment of specific diagnoses, type and frequency of other congenital anomalies and neoplasms, and gender assignment, as well as incidence of gender reassignment and transition. METHODS We performed a retrospective chart review of patients diagnosed with DSD conditions from 1995 to 2016 using ICD9 codes. For the purpose of this study, review was limited to individuals assessed to have neonatal "ambiguous genitalia" or "indeterminate sex." RESULTS Review identified 128 patients evaluated for ambiguous genitalia from 22 years of experience (Figure). Approximately half of these (53%) had 46,XY karyotype, 35% had 46,XX, and the remaining 12% had sex chromosome aberrations. Diagnostic rate for 46,XX DSD was higher at 64%, all of which were congenital adrenal hyperplasia, while diagnostic rate for 46,XY DSD was 11.7% for a molecularly confirmed diagnosis and 24% if clinical diagnoses were included. The most common anomalies included cardiac anomalies in 28/128 (22%), skeletal anomalies in 19/128 (15%), and failure to thrive or growth problems in 19/128 (15%). Additional congenital anomalies were found in 53 out of 128 patients (41%). There were three reported neoplasms in this group: gonadoblastoma, hepatoblastoma, and myelodysplastic syndrome with monosomy 7. Gender assignment was consistent with chromosomes in approximately 90% of XX and XY patients. There were three recorded gender reassignments or transitions. DISCUSSION Diagnostic rate for ambiguous genitalia is low, especially in 46,XY DSD. Most neonates were assigned gender consistent with their chromosomes. Given the high rate of associated anomalies, screening for cardiac or other anomalies in patients with ambiguous genitalia may be beneficial. CONCLUSION Patients with ambiguous genitalia often have additional congenital anomalies. Establishment of a specific diagnosis is uncommon in 46,XY patients. A few patients have gender reassignment outside of the newborn period. Ongoing collection of clinical data on this population may reveal new information regarding long-term health, quality of life, and establishment of more diagnoses with improved molecular techniques.
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Affiliation(s)
- Jennifer M Heeley
- Division of Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Abby S Hollander
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Paul F Austin
- Division of Urology, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Diane F Merritt
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | | | - Ina E Amarillo
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St Louis, MO, USA.
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Röhle R, Gehrmann K, Szarras-Czapnik M, Claahsen-van der Grinten H, Pienkowski C, Bouvattier C, Cohen-Kettenis P, Nordenström A, Thyen U, Köhler B. Participation of adults with disorders/ differences of sex development (DSD) in the clinical study dsd-LIFE: design, methodology, recruitment, data quality and study population. BMC Endocr Disord 2017; 17:52. [PMID: 28821302 PMCID: PMC5562972 DOI: 10.1186/s12902-017-0198-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND dsd-LIFE is a comprehensive cross-sectional clinical outcome study of individuals with disorders/differences of sex development (DSD). This study focuses on various rare genetic conditions characterized by impaired gonadal or adrenal functionality. METHODS/DESIGN The study aims to assess quality of life (QoL) as a measure of psychosocial adaptation, psychosexual and mental health aspects as major outcomes. Health status and functioning, medical and surgical therapies, participants' views on health care, psychological and social support, sociodemographic factors and their interrelations will be investigated as factors associated with the outcomes. In addition, ethical considerations in the field of DSD are addressed and previous experiences with health care were gathered. One thousand and forty participants with different DSD conditions were recruited by 14 study centres in 6 European countries (France, Germany, the Netherlands, Poland, Sweden and the United Kingdom) from February 2014 until September 2015. The conditions included were: Turner syndrome (n = 301); 45,X0/46,XY conditions (n = 45); Klinefelter syndrome (n = 218); 47,XYY (n = 1); 46,XY gonadal dysgenesis/ovotestes (n = 63); complete androgen insensitivity (CAIS) (n = 71); partial androgen insensitivity (PAIS) (n = 35) and androgen synthesis disorders (n = 20); severe hypospadias (n = 25); other or non-classified 46,XY DSD (n = 8); 46,XX congenital adrenal hyperplasia (CAH) (n = 226); 46,XX gonadal dysgenesis/ovotestis (n = 21); and 46,XX in males (n = 6). For an add-on study, 121 46,XY male-assigned individuals with CAH due to 21-hydroxylase deficiency were recruited. Mean age of participants' was 32.4 (+/- 13.6 years). DISCUSSION Participation was high in conditions not commonly described as DSD, such as Turner and Klinefelter syndromes or CAH. Recruitment of individuals with XY DSD conditions proved to be more difficult. The data collection of PROs resulted in high data quality. Within medical and physical examination data, more missings and/or inaccurate data were found than expected. The European dsd-LIFE study recruited and evaluated the largest cross-sectional sample of individuals with different conditions classified under the term DSD. The data from this large sample will provide a sufficient basis for evidence-based recommendations for improvement of clinical care of individuals affected by a DSD condition. TRIAL REGISTRATION German Clinical Trials Register DRKS00006072 .
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Affiliation(s)
- Robert Röhle
- Koordinierungszentrum Klinische Studien, (KKS), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Gehrmann
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maria Szarras-Czapnik
- Clinic of Endocrinology and Diabetology, Children’s Memorial Health Institute, Warszawa, Poland
| | | | - Catherine Pienkowski
- Unite d’Endocrinologie, Genetique et Gynecologie medicale, Hopital des Enfants, Toulouse, France
| | - Claire Bouvattier
- Endocrinologie pediatrique, Centre de reference des maladies rares du developpement sexuel, Hopital Bicêtre, Universite Paris-Sud, Paris, France
| | - Peggy Cohen-Kettenis
- Medische psychologie en medisch maatschappelijk werk, VU Medisch Centrum, Amsterdam, The Netherlands
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Department of Paediatric Endocrinology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin, Universität zu Lübeck, Lübeck, Germany
| | - Birgit Köhler
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Beale JM, Creighton SM. Long-term health issues related to disorders or differences in sex development/intersex. Maturitas 2016; 94:143-148. [PMID: 27823735 DOI: 10.1016/j.maturitas.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 09/19/2016] [Revised: 10/02/2016] [Accepted: 10/04/2016] [Indexed: 01/08/2023]
Abstract
DSD (Disorders or Differences in Sex Development) and Intersex are terms used to describe a diverse group of congenital conditions where the development of the reproductive system is different from what is usually expected. These conditions usually present at birth or adolescence and the health implications are wide ranging and often life-long. Given the complexity of many of the conditions, health care input when required should be provided by a multidisciplinary team who have appropriate expertise. Holistic care should include the consideration of the risk of cancer, prevention of osteoporosis, advice on hormones, sexual health and fertility options, and ongoing support in order to optimise quality of life and wellbeing. There is little evidence on the health of this group of individuals beyond middle age. Research in this field is essential to guide clinicians in providing high-quality care but also to allow affected individuals to make informed decisions about their own health care. This review will focus on the gynaecological aspects of multidisciplinary management.
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Affiliation(s)
- Jennifer M Beale
- Department of Women's Health University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.
| | - Sarah M Creighton
- Department of Women's Health University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.
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