Intersex Variations, Human Rights, and the International Classification of Diseases

Over time, the World Health Organization (WHO) has reviewed and removed pathologizing classifications and codes associated with sexual and gender minorities from the International Classification of Diseases (ICD). However, classifications associated with intersex variations, congenital variations in sex characteristics or differences of sex development, remain pathologized. The ICD-11 introduces additional and pathologizing normative language to describe these as "disorders of sex development." Current materials in the ICD-11 Foundation also specify, or are associated with, unnecessary medical procedures that fail to meet human rights norms documented by the WHO itself and Treaty Monitoring Bodies. This includes codes that require genitoplasties and gonadectomies associated with gender assignment, where either masculinizing or feminizing surgery is specified depending upon technical and heteronormative expectations for surgical outcomes. Such interventions lack evidence. Human rights defenders and institutions regard these interventions as harmful practices and violations of rights to bodily integrity, non-discrimination, equality before the law, privacy, and freedom from torture, ill-treatment, and experimentation. WHO should modify ICD-11 codes by introducing neutral terminology and by ensuring that all relevant codes do not specify practices that violate human rights.

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

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

Shifting syndromes: Sex chromosome variations and intersex classifications

The 2006 'Consensus statement on management of intersex disorders' recommended moving to a new classification of intersex variations, framed in terms of 'disorders of sex development' or DSD. Part of the rationale for this change was to move away from associations with gender, and to increase clarity by grounding the classification system in genetics. While the medical community has largely accepted the move, some individuals from intersex activist communities have condemned it. In addition, people both inside and outside the medical community have disagreed about what should be covered by the classification system, in particular whether sex chromosome variations and the related diagnoses of Turner and Klinefelter's syndromes should be included. This article explores initial descriptions of Turner and Klinefelter's syndromes and their subsequent inclusion in intersex classifications, which were increasingly grounded in scientific understandings of sex chromosomes that emerged in the 1950s. The article questions the current drive to stabilize and 'sort out' intersex classifications through a grounding in genetics. Alternative social and historical definitions of intersex - such as those proposed by the intersex activists - have the potential to do more justice to the lived experience of those affected by such classifications and their consequences.

Negotiating intersex: A case for revising the theory of social diagnosis

The theory of social diagnosis recognizes two principles: 1) extra-medical social structures frame diagnosis; and 2) myriad social actors, in addition to clinicians, contribute to diagnostic labels and processes. The relationship between social diagnosis and (de)medicalization remains undertheorized, however, because social diagnosis does not account for how social actors can also resist the pathologization of symptoms and conditions-sometimes at the same time as they clamor for medical recognition-thereby shaping societal definitions of disease in different, but no less important, ways. In this article, we expand the social diagnosis framework by adding a third principle, specifically that 3) social actors engage with social structures to both contribute to, and resist, the framing of a condition as pathological (i.e. medicalization and demedicalization). This revised social diagnosis framework allows for the systematic investigation of multi-directional, dynamic processes, formalizing the link between diagnosis and (de)medicalization. It also responds to long-standing calls for more contextualized research in (de)medicalization studies by offering a framework that explicitly accounts for the social contexts in which (de)medicalizing processes operate. To showcase the utility of this revised framework, we use it to guide our analyses of a highly negotiated diagnosis: intersex.

[Clinical evaluation and management of neonates with disorder of sexual development]

Disorder of sexual development or disorder of sex differentiation (DSD) refers to the inconsistency between karyotype and gonad phenotype and/or gonad anatomy in neonates and is manifested as the difficulty in identifying neonates' sex. According to the karyotype, DSD is classified as 46,XY DSD, 46,XX DSD, and sex chromosome DSD. A combination of detailed medical history, physical examination, and laboratory and imaging examinations is required for the diagnosis and comprehensive assessment of neonatal DSD and the determination of potential causes in clinical practice. Sex identification can only be made after all diagnostic evaluations have been completed. Sex identification of DSD neonates is influenced by various medical and social factors, including genotype (karyotype), sex hormones (levels of testosterone, dihydrotestosterone, and adrenal steroids), sex phenotype (appearance of internal and external genitals), reproduction (fertility potential), feelings of their parents, and even social acceptance and religious customs. A team with multidisciplinary cooperation is required, and patients must be involved in the whole process of sex identification. The major task of neonatal physicians for DSD is to assess the condition of neonates and provide management.

Classifying Intersex in DSM-5: Critical Reflections on Gender Dysphoria

The new diagnosis of Gender Dysphoria (GD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines intersex, renamed "Disorders of Sex Development" (DSD), as a specifier of GD. With this formulation, the status of intersex departs from prior editions, especially from the DSM-IV texts that defined intersex as an exclusion criterion for Gender Identity Disorder. Conversely, GD--with or without a DSD--can apply in the same manner to DSD and non-DSD individuals; it subsumes the physical condition under the mental "disorder." This conceptualization, I suggest, is unprecedented in the history of the DSM. In my view, it is the most significant change in the revised diagnosis, and it raises the question of the suitability of psychiatric diagnosis for individuals with intersex/DSD. Unfortunately, this fundamental question was not raised during the revision process. This article examines, historically and conceptually, the different terms provided for intersex/DSD in the DSM in order to capture the significance of the DSD specifier, and the reasons why the risk of stigma and misdiagnosis, I argue, is increased in DSM-5 compared to DSM-IV. The DSM-5 formulation is paradoxically at variance with the clinical literature, with intersex/DSD and transgender being conceived as incommensurable terms in their diagnostic and treatment aspects. In this light, the removal of intersex/DSD from the DSM would seem a better way to achieve the purpose behind the revised diagnosis, which was to reduce stigma and the risk of misdiagnosis, and to provide the persons concerned with healthcare that caters to their specific needs.

Consequences of the Chicago DSD Consensus: A Personal Perspective

A decade has passed since the Chicago Consensus meeting was convened to consider how to improve the management of individuals and their families with an intersex disorder. It is apposite to review, from an individual perspective, what impact the Consensus has had on clinical practice and research. Emphasis is placed on nomenclature and DSD classification, multidisciplinary team working, striving to reach a causative diagnosis for DSD, the value of uniformity of collective case registries for rare conditions, and the potential for meaningful clinical outcome studies and basic scientific research. The impact of the Consensus can be gauged objectively by an exponential increase in DSD-related publications in the medical and scientific literature and organisation of numerous national and international meetings. Psychologists and social scientists have embraced the subject area and enhanced the holistic approach to management of DSD. Much needs to be done to improve diagnosis, and to identify measures to predict outcome that can be used both in sex assignment decision-making and to improve the quality of life for young adults with DSD. Though challenging, these goals are attainable through specialist multidisciplinary clinics working at local level and the DSD community at large, collaborating at national and international levels to tap the data resources now being developed.

Transforming sexuality: the medical sources of Karl Heinrich Ulrichs (1825-95) and the origins of the theory of bisexuality

This article explores the medical references in the writings of the German jurist and activist Karl Heinrich Ulrichs as a means of breaking new ground in diverse fields (including history of medicine, history of sexuality, and gender history). It demonstrates that the theory of bisexuality has a much deeper and more textured genealogy than has been hitherto appreciated and that dual-gendered bodies and minds must be better recognized as important through the nineteenth century. Specifically, it demonstrates that classifications and rhetoric of hermaphroditism, and other dual-gendered categories (e.g., sexual dualism and anatomical bisexuality), were deployed in diverse contexts through the period, often with little or no reference to the occurrence of genital ambiguities. Important discourses in embryology, utilized by Ulrichs, suggested that all individuals, in the earliest stages of fetal development, were hermaphroditic. In making an analogy among the ontogeny of sex anatomy, hermaphroditism, and the development of erotic preferences, Ulrichs sought to naturalize homoeroticism, rendering social and legal prohibitions untenable. His advocacy, however, was counterbalanced by the Prussian forensic expert Johann Ludwig Casper who had made some conceptual maneuvers similar to Ulrichs only couched in the rhetoric of pathology. Ulrichs was equivocal in his use of forensic works such as Casper's, condemning their authors but recognizing similarities with his own gender schema.

How should we classify intersex disorders?

The term disorders of sex development (DSD) has achieved widespread acceptance as replacement for the term intersex, but how to classify these conditions remains problematic. The LWPES-ESPE (Lawson Wilkins Pediatric Endocrine Society and European Society of Paediatric Endocrinology) Consensus Group proposed using the karyotype as a basis for classification; however, this is but a crude reflection of the genetic makeup, is diagnostically non-specific, and is not in itself relevant to subsequent clinical developments. The historical classification of intersex disorders based on gonadal histology is currently out of favor, being tainted by association with the terms hermaphroditism and pseudohermaphroditism. We believe this is regrettable, for the histology of the gonad remains fundamental to the understanding of normal and aberrant sexual development by medical students and residents in training, as well as being a major determinant of clinical outcome for the patient. We propose a comprehensive classification of those DSD conditions generally regarded as belonging under the heading of intersex, based on gonadal histology. Biopsy will not be required when the diagnosis is clearly established biochemically or by gene studies as the histology can be confidently predicted. It will only be required when an ovotestis or dysgenetic gonad is suspected in order to determine the definitive diagnosis.

Laboratory investigations in genetic syndromes: examples of clinical approach in the neonatal unit

Contiguous gene deletion syndromes: the importance of an accurate genetic definition for a careful clinical monitoring. Contiguous gene deletion syndromes are so named because the deletion manifests as a distinctive cluster of otherwise unrelated single-gene disorders in the same subject. An accurate genetic definition of the deleted region is extremely important for the appropriate management of these patients and for unravelling the function of the involved genes. The microarray-based comparative genomic hybridization (CGH arrays) analysis is the actual molecular method able to accurately define the bounds of a deleted region, since it allows an evaluation of DNA copy number alterations associated to chromosome abnormalities, with higher resolution than classical cytogenetics or chromosomal banding. The clinical presentation, the diagnostic course, the genetic investigations and the follow-up of a patient harbouring a contiguous gene deletion syndrome will be presented during the seminar. The newborn with ambiguous genitalia: diagnostic approach toward clinical and genetic definition. Disorders of sexual differentiation may depend on several different causes and pathogenetic mechanisms, which may interfere at different stages of the complex pathway of sexual determination and differentiation. Several genes are involved, together with hormones and receptors. The main disorders of sexual differentiation are characterized by dissociation between chromosomes and gonads or gonads and external genitalia appearance. Clinical phenotypes may be distinguished in true hermaphroditism and male or female pseudohermaphroditism. Diagnostic definition is based on clinical and instrumental evaluation and laboratory investigations (hormonal, cytogenetic and molecular genetic investigations). Early diagnosis may allow an appropriate medical and/or surgical treatment, involving a multidisciplinary equipe. The correct gender assessment must be guided by clinical and genetic diagnosis and, in the meantime, by the possibility of anatomic and functional recovery and the future reproductive opportunities.

Impact of the consensus statement and the new DSD classification system

In 2006, a task force of 50 specialists sponsored by the European Society for Paediatric Endocrinology (ESPE) and the Lawson Wilkins Pediatric Endocrine Society (LWPES) devised a Consensus Statement outlining the recommendations for the management of disorders of sex development (DSDs; then referred to as 'intersex' disorders) as well as proposing a new nomenclature and DSD classification system. In the 2 years subsequent to its publication, the Statement has been widely cited and endorsed in the literature as a model for patient care. In addition, much of the scientific literature incorporates the newly proposed nomenclature and classification system as part of its own discourse. However, without a systematic analysis of the uptake of recommendations of the Statement, it is not possible to make valid conclusions regarding the uptake of the recommendations within clinical practice. Here we discuss the Consensus Statement and its impact with respect to the newly proposed nomenclature and psychosocial management according to a new study following 60 DSD centres throughout Europe. Finally, we discuss future directions for research in the management of DSD, beginning at the moment of disclosure.

The quiet revolution: Disorders of sex development

The approach to the management of disorders of sex development (DSD) has undergone major changes in recent years. The catalyst has been a revised nomenclature, new classification of the causes of DSD and a willingness for health professionals to work in a multi-disciplinary format. In a remarkably short length of time, these revolutionary changes are becoming accepted practice across a range of medical and scientific disciplines.

Gender verification in athletes with disorders of sex development

Disorders of sex development (DSD) are most controversial issue in gender verification of athletes. To make a more scientific, accurate and humanitarian decision for athletes is the target of gender verification. In this article, we evaluate the used methods of gender verification in athletes, recommend a useful simplified classification of DSD and propose a comprehensive etiological diagnostic system based on this classification for gender verification in athletes.

Disorders of sex development (DSDs), their presentation and management in different cultures

The way disorders of sex development (DSD) are viewed and managed in different cultures varies widely. They are complex conditions and even well-educated lay people find them difficult to understand, but when families are very poor and lacking in basic education, and the health system is starved of resources, traditional beliefs, folk remedies and prejudice combine to make the lives of children and adults with DSD extremely difficult and sad. Rumour and discrimination isolate them from their communities and they become devalued. People with DSDs desire the same things in life as everyone else-to find someone who will love them, to be valued as human beings, to feel at home in their own bodies, to be able to have satisfactory sexual relations should these be desired, to be able to trust their medical advisers and to be integrated into the general community. Long term outcome studies have been published from many countries, but these studies have not necessarily been critical of the values that underpinned the type of treatment given to the patients. There is a need for standardized instruments that would allow a true comparison of the quality of outcomes from the patients' perspective. Much could be done to improve equity between rich and poor countries for the benefit of people with DSDs. A focus on developing cheap, robust diagnostic tests, making essential medicines available for all, training surgeons to do better operations, educating health professionals, families and the general community in order to break down prejudice against people with DSDs, and training mental health workers in this specialized field, would do much to alleviate the burden of the condition.

Disorders of sex development: a new definition and classification

A newborn infant with ambiguous genitalia is a complex enough problem to unravel without any further clouding by confusing terms. The nomenclature 'intersex', 'hermaphrodite' and 'pseudohermaphrodite' is anachronistic, unhelpful, and perceived to be pejorative by some affected families. In its place, a consensus statement recommends the term 'disorder of sex development' (DSD), a generic definition encompassing any problem noted at birth where the genitalia are atypical in relation to the chromosomes or gonads. The karyotype is used as a prefix to define the category of DSD, replacing the arcane terminology of male or female pseudohermaphroditism (now known as XY DSD or XX DSD, respectively). The new nomenclature has spawned a simple and logical classification of the causes of DSD. In this chapter new facets of gonadal dysgenesis and novel defects in steroid biosynthesis are reviewed in relation to the DSD classification, and options for early, non-invasive fetal sexing are described. Future research to determine many causes of DSD will benefit from the use of this universal language of scientific communication.

ORIGINAL RESEARCH–INTERSEX AND GENDER IDENTITY DISORDERS: Male Gender Identity in an XX Individual with Congenital Adrenal Hyperplasia

INTRODUCTION

In spite of significant changes in the management policies of intersexuality, clinical evidence show that not all pubertal or adult individuals live according to the assigned sex during infancy.

AIM

The purpose of this study was to analyze the clinical management of an individual diagnosed as a female pseudohermaphrodite with congenital adrenal hyperplasia (CAH) simple virilizing form four decades ago but who currently lives as a monogamous heterosexual male.

METHODS

We studied the clinical files spanning from 1965 to 1991 of an intersex individual. In addition, we conducted a magnetic resonance imaging (MRI) study of the abdominoplevic cavity and a series of interviews using the oral history method.

MAIN OUTCOME MEASURES

Our analysis is based on the clinical evidence that led to the CAH diagnosis in the 1960s in light of recent clinical testing to confirm such diagnosis.

RESULTS

Analysis of reported values for 17-ketosteroids, 17-hydroxycorticosteroids, from 24-hour urine samples during an 8-year period showed poor adrenal suppression in spite of adherence to treatment. A recent MRI study confirmed the presence of hyperplastic adrenal glands as well as the presence of a prepubertal uterus. Semistructured interviews with the individual confirmed a life history consistent with a male gender identity.

CONCLUSIONS

Although the American Academy of Pediatrics recommends that XX intersex individuals with CAH should be assigned to the female sex, this practice harms some individuals as they may self-identify as males. In the absence of comorbid psychiatric factors, the discrepancy between infant sex assignment and gender identity later in life underlines the need for a reexamination of current standards of care for individuals diagnosed with CAH.

Neoplasms and pathology of sexual developmental disorders (intersex)

Continuing new insights into the biology of sexual development and advances in chromosome analysis have led to early identification and prompt treatment of the intersexual patient, the results of which facilitate a more normal life for affected individuals. Based on these advances, a classification of abnormal sexual development has been developed and refined that correlates the gonadal and genital anatomy with the chromosomal findings and specific genetic or metabolic defects. In a shift from a classification anchored on whether the intersex revolves about a specific gene or whole chromosomal abnormality, the current classification is organised by broader categories into which the intersexual disorders are divided into 'abnormalities of genital differentiation', due largely to the abnormal production or sensitivity of a single hormone, or 'abnormalities in sex determination', due to abnormal gonadal differentiation, usually testicular, with or without chromosomal aberration. The current classification is an integrated approach to this complex group of disorders and is organised according to the manner by which patients present as well as on the pathophysiological basis of the defect. The classification also groups patients who are at high risk for development of gonadal neoplasia.

Early management and gender assignment in disorders of sexual differentiation

Ambiguous genitalia, sine qua non, defines a congenital endocrinopathy. The problem is immediately apparent at birth and prompts an urgent response in management which requires input from a multi-disciplinary team of experts. Assignment to a male or female gender is instantaneous when a baby is born. That this may not be possible in rare instances is immensely distressing to affected families. Indeed, abnormalities of the external genitalia sufficient to warrant genetic and endocrine studies occur in 1 in 4,500 births. There has been considerable progress in improved diagnosis and early management in recent decades, particularly with respect to congenital adrenal hyperplasia, the commonest cause of ambiguous genitalia of the newborn. For the purposes of this chapter, attention is focussed on the newborn with ambiguous genitalia and subsequent management in infancy and early childhood.

Changing the nomenclature/taxonomy for intersex: a scientific and clinical rationale

We explain here why the standard division of many intersex types into true hermaphroditism, male pseudohermaphroditism, and female pseudohermaphroditism is scientifically specious and clinically problematic. First we provide the history of this tripartite taxonomy and note how the taxonomy predates and largely ignores the modern sciences of genetics and endocrinology. We then note the numerous ways that the existing taxonomy confuses and sometimes harms clinicians, researchers, patients, and parents. Finally, we make six specific suggestions regarding what a replacement taxonomy and nomenclature for intersex should do and not do, and we call for the abandonment of all terms based on the root "hermaphrodite".

Idiopathic male pseudohermaphroditism is associated with prenatal growth retardation

About 50% of intersex cases are due to male pseudohermaphroditism, and of these cases, 50% are not clarified aetiologically. The association of idiopathic male pseudohermaphroditism and prenatal growth retardation has been recently reported. The aim of this study was to verify whether there was a difference in weight and/or length at birth between idiopathic and non-idiopathic male pseudohermaphroditism patients. A total of 70 patients with male pseudohermaphroditism were recruited; 35 non-idiopathic and 35 idiopathic. Birth weight and length were converted to z scores, and the severity of genital ambiguity was classified according to Prader grades: less virilized (Prader 1 to 3) and more virilized (Prader 4 or 5). Data were analysed using a Mann-Whitney test, odds ratio and logistic regression analysis. Birth weight (P = 0.028) and length (P = 0.01) z scores were lower in the idiopathic male pseudohermaphroditism group compared to the non-idiopathic group and were also significantly decreased among the less virilized patients, both in the sample as a whole (weight z score, P = 0.002; length z score, P = 0.0008) and in the group of idiopathic patients (weight z score, P = 0.013; length z score, P = 0.007). According to logistic regression analysis, only birth length z score significantly predicted the severity of the genital ambiguity in patients with idiopathic male pseudohermaphroditism ( P = 0.0007).

CONCLUSION

There is an association between prenatal growth retardation and male pseudohermaphroditism which may be due to genetic factors not clarified yet or to environmental factors which act early in gestation.

Hormonal therapies for individuals with intersex conditions: protocol for use

Hormonal therapy forms part of the treatment of every intersex condition. For some conditions, such as salt-wasting congenital adrenal hyperplasia, hormonal replacement therapy is life saving because hormones necessary for survival (cortisol and aldosterone) are replaced. In contrast, other hormones such as androgens or mineralocorticoids are secreted in excessive amounts in congenital adrenal hyperplasia due to an enzyme imbalance, and the role of hormonal therapy is to suppress the unwanted hormone excess by exerting negative feedback. For patients with one of the many causes of hypogonadism, sex hormone replacement therapy may be prescribed to stimulate sexual development: growth of a hypoplastic penis in a young boy, pubertal changes (male or female), psychosexual development, and adult sexual behavior. It has equally important and highly beneficial effects on bone mineral density. Hormonal therapy is also used to treat the unborn child. For the last 20 years, prenatal dexamethasone treatment administered to the pregnant woman has been used to prevent the development of ambiguous genitalia in females with 21-hydroxylase deficiency. Outcome studies show this treatment to be well tolerated and, in general, efficacious. Intersex conditions are, however, difficult to treat because they may intrinsically perturb complex aspects of the person's gender identity, gender-role behavior, sexual orientation, sexual functioning, and psychologic adjustment. Furthermore, decisions made about the sex of an infant by doctors and parents do not always turn out to be correct; the person may grow up feeling uncertain about his or her gender identity, or worse still, harbor a sense of outrage about their life and treatment experiences. Such a person will have definite views about hormonal therapy when the time comes and skillful counseling will be needed. A vigorous debate about ethical aspects of current medical practices relating to intersex conditions has been waged for the last 7 years between certain patient advocacy organizations and the medical profession, and is expected to continue for some time. The quality of the debate will be improved by evidence. The results of a number of long-term follow-up studies have been published, and more are expected. The published studies show mixed, but mainly encouraging, results.

A new classification for genital ambiguity and urogenital sinus anomalies

OBJECTIVE

To describe a new system for classifying genital ambiguity and urogenital sinus abnormalities. Prader's classification (which attempts to describe the degree of masculinization) has been used for decades, while the urogenital sinus has generally been described as simply high or low; neither classification fits the spectrum of anomalies, nor do they allow for outcome data research.

METHODS

An ideal description of genital ambiguity and urogenital sinus anomalies should include the degree of masculinization, phallic size, external genital appearance, and the true location of the vaginal confluence in relation to the bladder neck and the perineal meatus. We describe a new system to define these variables.

RESULTS

In the PVE classification developed, P represents stretched phallic length and width, V the true vaginal location according to the distance from the bladder neck to the vagina and the distance from the vagina to the perineal meatus, and E the external genital appearance or Prader number.

CONCLUSIONS

The PVE classification system aids in surgical planning and will be helpful in the analysis of surgical outcomes of genital ambiguity and urogenital anomalies.

A practical approach to intersex

The realm of intersex presents a challenge to the family as well the health care provider. As the physical aspects of diagnosis and management have become better understood, it has become apparent that there are psychological and social aspects that we have only begun to understand. A general overview of intersex issues that may confront the urologic practitioner, and the current concepts of diagnosis and management, are provided.

A ranking system for the evaluation of intersex condition in European flounder (Platichthys flesus)

Intersex (ovotestis) is the condition whereby an individual possesses oocytes, at varying degrees of severity, within the normal testicular tissue and is regarded as an endpoint of endocrine disruption in male fish. The occurrence of intersex has been linked with exposure to endocrine-disrupting compounds present in the environment, which are thought to mimic the actions of the female sex hormone 17-beta-oestradiol. Using stained histological sections of archived cases of intersex from European flounder (Platichthys flesus), this study developed a grading method to assess the extent of the condition. This was termed the ovotestis severity index (OSI). The OSI utilizes the distribution pattern (focal, diffuse, cluster, zonal) and type of oocyte (previtellogenic, cortical alveolar, vitellogenic) to assign a severity rating to each intersex fish. A high OSI refers to fish with testicular material almost completely replaced with mature (vitellogenic) oocytes, and lower scores indicate those fish with small numbers of immature (previtellogenic) oocytes. The development of this index provides pathologists with a robust tool for the grading of the intersex condition in European flounder and potentially in other fish species.

[Grouping of abnormal sexual development--guide to diagnosis]

Sexual differentiation and development is a process from the moment of fertilization of a ovum by a spermatozoon to achievement of reproductive ability as a male or female. The process includes three steps; establishment of sex chromosome composition, gonadal differentiation and development, and acquirement of phenotypic expression by gonadal hormones. Therefore, abnormal sexual development is divided into three categories according to the above three steps. In humans, however, gender is assigned at birth. Then, individuals grow under social environment provided according to the gender assigned and acquire gender role during childhood and gender identity during puberty. As observed in those with trans-sexualism, it appears likely that gender identity plays a major role on sexual behavior of humans.

[Variants of hermaphroditism (clinical findings)]

False and true hermaphroditism (FH and TH) are often encountered in surgery for hypospadia. A clinically validated classification of various types and variants of hermaphroditism is proposed. FH is divided into male FH and female FH. TH also falls into two categories: TH without anomalies of external genitalia and that with these anomalies. The latter category has three variants: 1) all genitalia of males or females and some genitalia of the other sex; 2) some female and male organs in various combinations; 3) all organs of both sexes. All TH variants are illustrated by 5 case reports. These patients were thoroughly examined and their sex was surgically corrected.

Defining, assigning and designing sex

This article challenges the distinction the law draws between male and female. It focuses on the legal and medical treatment of intersexual people. Analysing the nature and rate of intersexuality it argues that there is a significant number of people who cannot be described as either male or female and instead exhibit a range of sexual characteristics. Until recently the law and medicine have insisted that intersexual people should be categorized as either male or female. Surgery was performed to ensure that they had the appearance assumed to be the 'norm' for a man or woman and the law followed this medical assignment of sex. Over the last couple of years the established medical practice and the legal treatment have been challenged. This article discusses the nature of these challenges and argues that there is a strong case for rejecting the traditional legal and medical approach to intersexual people. Cosmetic surgery on intersexual babies should be delayed until the individual is old enough to be able to choose their own sexual identity, which may be neither male nor female. The insistence that every person must either be male or female is no longer supportable in medical or social terms and a much wider range of sexual identities must be recognized by the law.

Quality assurance of imposex and intersex measurements in marine snails

Collaboration between the QUASIMEME and BEQUALM projects has proved to be an effective mechanism to further the development of quality assurance procedures for the measurement of the biological effects of tributyltin (imposex and intersex) to meet the requirements of international and national marine monitoring programmes. The data arising from the Laboratory Performance Studies are demonstrating the level of agreement between laboratories, suggesting factors leading to differences between laboratories, and guiding the development of QA procedures.

Syndromal (and nonsyndromal) forms of male pseudohermaphroditism

The term sex determination refers to the genetic events that bring about male or female gonadal development; sex differentiation to all subsequent morphogenetic and physiological events that establish functional sexuality, sexual dimorphism and the secondary sexual characteristics. Virtually all of the steps of sex differentiation are under genetic control; consequently each one of them can fail as result of mutation of the corresponding genes. We shall be concerned with those genes and their mutations that cause pseudohermaphroditism in males and more rarely in females (with the exception of congenital adrenal hyperplasia). Special emphasis will be placed on Swyer, Denys-Drash, RSH, GBBB, campomelic and ATR-X syndromes, whose genes were recently identified.

[Malformations of the scrotum and its contents]

To introduce we report the embryological origin of the male genitals and we present the endocrine control of the sex phenotypic differentiation and the most important features of the sexual differentiation abnormalities (ambiguous genitalia of newborn, gonadal dysgenesis, chromosome anomalies). Subsequently we report the classification of cryptorchidism and its correlation with hormonal and histological abnormalities. Furthermore we tried to expose the various different thoughts about testicular descent, anomalies associated with cryptorchidism and implications with malignant degeneration and infertility. Finally we describe the Magenta hospital experience from 1972 to 1998 reporting the surgical procedures for undescended testicle and for scrotal anomalies.