Intersex

1. Intersex • What is Intersex? • Examples of DSD • History • Examples of intersex condition • Treatment /Hormonal induction of Puberty • Surgery • % Of Intersex Opting to Change Sex • Support from medical professionals should include • Conclusion

2. What is Intersex? • Intersex is a group of conditions where there is a discrepancy between the external genitals and the internal genitals (the testes and ovaries). The older term for this condition is hermaphrodites.  • According to Bertelloni (2008) DSD are rare conditions in total one person in about 5,500 is affected.

3. Examples ofDisorders of Sexual Development (DSD) • Complete Androgen Insensitivity Syndrome (CIAS) Has a female external appearance despite a 46XY karyotype and undecendedtestes; a condition termed "testicular feminization" in the past. • Partial Androgen Insensitivity Syndrome Androgen insensitivity syndrome (AIS) is when a person who is genetically male (has one X and one Y chromosome) is resistant to male hormones called androgens. As a result, the person has some or all of the physical characteristics of a woman, despite having partial fusion of the outer vaginal lips. • 5a-Reductase type 2 deficiency 5-alpha-reductase deficiency (5-ARD) is an autosomal recessive intersex condition caused by a mutation of the 5-alpha reductase type 2 gene. Normal function 5-alpha-reductase is an enzyme that converts testosterone... • Ovotesticular DSD The presence of Y chromosome confers a high risk of neoplastic transformation in dysgenetic gonads. The neoplastic development in these patients is associated with the presence of Y chromosome and intra abdominal location of the abnormal gonad. (Dictionary.com)

4. Examples ofDisorders of Sexual Development (DSD) • Mixed Gonadal Dysgenesis (MGD) refers to individuals who usually have a differentiated gonad on one side and a streak gonad or streak testis on the other side. A differential diagnosis between the TH and MGD has important clinical implications for gender assignment and the decision for early gonadectomy. • 46,XY Complete Gonadal Dysgenesis (46,XY CGD) is characterized by a 46,XY karyotype, normal female external genitalia, completely undeveloped (”streak”) gonads, no sperm production, and presence of normal Müllerian structures. • 17-hydroxysteroid dehydrogenase-3 (17B-HSD-3) Deficiency (Dictionary.com)

5. History 1 It was first assumed that children are psychosexually neutral at birth. Until a publication of a studied came out that suggested prenatal brain exposure to sex hormones determines gender development. In the 1950s, the well known psychologist John Money and his co-workers at the John Hopkins University Hospital in Baltimore were the first to conduct follow up studies on intersex patients. Because, in their work, gender largely seemed to follow the gender of rearing, they concluded that gender assignment and rearing, and not the chromosomal, gonadal or genital sex, was the best predictor of adult gender identity. (Cohen-Kettenis, P .2005 (1)

6. History 2 • As a consequence the “true sex policy “was replaced by the so called “optimal gender policy”, according to witch gender assignment was based on the expected optimal outcome in terms of psychosexual, reproductive and over all psychological functioning. Because gender appropriate rearing was considered to be crucial for gender identity development, early surgery was recommended to facilitate this. • As gender identity was assumed to depend entirely on the environment, this female sex assignment in all 46,xy with functionally inadequate penis. At this time, very little was known about sexual differentiation of the brain. So, the theory of ‘psychosexual neutrality’ at birth prevailed. Since the 1950s, this paradigm was increasingly challenged by a number of studies in the field of neuroscience. . (Cohen-Kettenis, P .2005 (2)

7. History 3 First sex-dimorphic brain nuclei were found in animals and humans as a consequence, prenatal exposure of the brain to androgens was increasingly put forward as a factor in gender identity development. Second several studies on neuroendocrine effects on gender-atypical behaviors, traits, preferences and activities. In these studies evidence was found of an influence of sex steroids on a wide range of behaviors. . (Cohen-Kettenis, P .2005 (3) Third, studies were carried out on the long-term out-come of gender identity in individuals with various intersex conditions. For example a baby boy, one of a pair of twins, lost his penis during circumcision. Along the lines of the optimal gender policy, the boy was reassigned as a girl at 15 months. Regrettably, the child turned out to be increasingly unhappy as a girl. At 14, she was informed that she had been born a boy. From that moment on she resumed the male role. In this case, biology seemed to clearly determine gender identity. This outcome seemed to be in line with a number of follow –up studies among intersex patients, in particular 5a-reductase-2 deficiency. (Cohen-Kettenis, P .2005 (4) The percentage of gender changes varies depending on the condition. This may imply that prenatal androgen exposure of the brain is more important for gender development than has long been believed. (Cohen-Kettenis, P .2005 (8)

8. Examples of intersex condition True hermaphrodites have both male and female organs, often because of abnormal chromosomes. ”Ferms”(female pseudoherma-phrodites) are genetic females who’s sex organs were masculinizes through prenatal exposure to testosterone. ”Merms ” are genetic males who failed to produce the necessary hormones or whose tissue failed to respond to them. (Sillars, 1998 P 10-11)

9. Examples of intersex condition The results are often bizarre and produce lives filled with emotional upheaval depression and debilitating side effects from years of drug treatment and surgeries, according to the Intersex Society of North America (ISNA), a group witch objects to surgical reassignment of infants. At the age of 12, reports one member, ”My body began to go haywire. My hips spread and my voice began to break. My breasts grew, and so did my facial hair, "Some genetic females have been raised as boys because of the presence of male genitals, only to start menstruating at age 13. (Sillars, 1998 P 10-11)

10. Video http://search.live.com/video/results.aspx?q=intersex+children&docid=417119273197&mid=856E9BA69F35ABE34F92856E9BA69F35ABE34F92&FORM=VIVR35

11. Treatment and hormonal induction of pupertyusual occurs between 11 and 13 years of age • Testosterone Gel Patch Oral Injections • Androgen DHT gel Oral Injections Implant  (Bertelloni, 2008)

12. Surgery • Gives rise in feeling in loss of body ownership. • May regret surgery after its performed • Irreversible Surgical damage may accrue • Constant surgery can be a constant reminder of their differences. • A need for on going treatment (med. for infections) • The need for additional surgeries when the first is unsuccessful • Vaginal dilation witch at a young age leads to severe psychological problems. (Nihoul-Fekete, 2005)

13. % Of Intersex Opting to Change Sex • Congenital Adrenal Hyperplasia (CAH) A study took 250 patients raised as females. Out of the 250, 32 had male assessment at birth, but 28 were reassigned within the first 19 months. At the follow up 9.2% experienced problems related to gender identity. However, only 1.6% made gender changes. • Androgen Insensitivity Out of 99 cases (55 assigned females and 44 assigned males) 9 of them decided to change gender later in life.6 Changed from male to female. In 3 of the cases the child had female assignment at birth, but were than reassigned and then raised as boys.3 other cases were female to malechanges.1 child had a male assignment at birth, but was reassigned as femalelater.

14. % Of Intersex Opting to Change Sex • 5a-RD-2 and 17B-HSD-3 • 5a-RD-2 Out of 100 raised patients (56%) 62 changed gender from female to male. • 17B-HSD-3 On patients with 17B-HSD-3 had a gender change of 39% (19 of 49). In the case of adolescence raised as boys, no changes in gender were reported. • (Cohen-Kettenis, 2005)

16. Attention to family/patients concerns Providing accurate information to the patient/family Be aware and acknowledge important biological determinants To minimize psychological distress, patients /family should Be told exactly what will be done and why. Support from medical professionals should include • Open communication • Management evaluations   • Respect • Strict confidentiality   (Cohen-Kettenis, P .2005)

17. Conclusion From the beginning you’re reared according to your anatomy and your genitals. The intersexes, the people who don’t always speak out, have feelings and are humans too. We as people have lived life in accordance to labels, but it isn’t fair to live life as being labeled some thing more or less than you really are. If were all unique as individuals wouldn’t that be consider normal anyway? Living with (DSD), some Adolescence start to experience side effects during puberty that normal adolescence might not. They spend time in hospitals having surgery, hormonal treatment, and suffer with depression. They sometimes seem lost and confused.

18. Conclusion • The percentage of gender changes depends, on the person’s condition and personal preference. This may imply that androgen exposure to the brain during fetal development plays a role in gender identity. However, rearing a child as middle sex may cause psychological damage. It is best to raise a child with one sex or the other, but not both. • Finding the support that Adolescence need is very critical. Being sensitive to their condition, showing respect, and concern will hopefully minimize any negative impact .If we keep an open mind we might gain a better insight in to the crucial factors of gender identity and how they effect adolescence. (Cohen-Kettenis, P .2005)