Disorders of sex development

Disorders of sex development (DSD), sometimes referred to as disorders of sex differentiation or differences of sex development,^[1] are medical conditions involving the reproductive system. More specifically, these terms refer to "congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical."^[2] The term has been controversial; the World Health Organization and many medical journals still reference DSDs as intersex traits or conditions.^[3] The Council of Europe,^[4] and Inter-American Commission on Human Rights^[5] have called for a review of medical classifications that unnecessarily medicalize intersex traits.^[4][5][6]

Overview

DSDs are medical conditions involving the way the reproductive system develops from infancy (and before birth) through young adulthood. There are several types of DSDs and their effect on the external and internal reproductive organs varies greatly.

A frequently-used medical adjective for people with DSDs is "intersex". Intersex literally means that the body is between the two sexes, male and female. Nevertheless, most intersex people think of themselves as completely being either boys/men, or girls/women. For this reason, parents with DSD children and clinicians involved in DSD treatment usually try to make clear distinctions between biological sex, social gender, and sexual orientation. This helps reduce confusion about the differences between being intersex, being transgender, and being gay/lesbian.

The most common DSD is Congenital Adrenal Hyperplasia (CAH), which results in a person with female (XX) chromosomes having genitals that look somewhat masculine. In mild cases CAH results in a slightly enlarged clitoris, while in more severe cases it can be difficult to decide (just by looking) whether a baby is male or female (this is called having ambiguous genitals). Nevertheless, if they are old enough to know the difference, most children with CAH think of themselves as girls. CAH is caused by a problem with the adrenal glands and is usually treated by taking a daily medication to replace or supplement the missing adrenal hormones. (When this adrenal problem occurs in people with male (XY) chromosomes, the result is over-masculinization and premature puberty).

Another common DSD is Androgen Insensitivity Syndrome (AIS), which means that a person with male (XY) chromosomes does not respond to testosterone in the usual way. This results in a body that to some degree has a feminine appearance. In Complete Androgen Insensitivity Syndrome (CAIS) the result is a totally feminine appearance, including typical female breast development. Consequently, most young women with CAIS are unaware of their condition until the early teen years when they fail to menstruate. In the milder form, called Partial Androgen Insensitivity Syndrome (PAIS), the genitals can vary from mostly female to almost completely male. Some people with PAIS think of themselves as girls/women, others regard themselves as boys/men, and some consider themselves mixed-gender. Some people with PAIS take hormones and/or undergo surgery to give the genitals a more ordinary appearance. In the past such surgeries were often performed in infancy, but in recent years the tendency has been to postpone surgery until the child has expressed a clear gender preference and is old enough to participate actively in decisions about his/her medical treatment.

One of the more unusual DSDs is 5-Alpha Reductase Deficiency (5ARD), popularly known as "Penis at 12." It is caused by a shortage early in life of an enzyme that activates testosterone. In this condition, a person with male (XY) chromosomes has a body that appears female before puberty. After puberty begins, other testosterone-activating enzymes become available and the body soon takes on a masculine appearance, with the scrotum and penis usually reaching typical or nearly-typical size. If 5ARD is diagnosed at a young age, the child is generally raised as a boy, since the majority of adults with this condition consider themselves men.

In addition to CAH, CAIS, PAIS, and 5ARD there are several rarer types of DSDs, and in some cases it is not possible to make a clear diagnosis of the underlying condition.

The penis and clitoris are essentially the same organ (differing only in size, and generically called the phallus). In typical males, the urethra is located at the tip of the penis, while in typical females the urethra is located below the base of the clitoris. When the phallus is of intermediate size, it is possible also to have a urethral opening located along the shaft; this condition is known as hypospadia.

Open-minded parenting, appropriate and conservative medical intervention, and age-appropriate child involvement in the treatment plan contribute greatly to successful outcomes for the entire range of DSDs.^[7]

Conditions

• 47,XXY females and Non-Klinefelter XXY - There are case reports of 47,XXY females; in some cases SRY or androgen receptor abnormalities are detected.^[8]
• 48, XXXX (also known as tetrasomy X, quadruple X, and XXXX syndrome) - A condition that describes a female with two extra female chromosomes. It is considered a variation of Triple X syndrome. Women with 48, XXXX may or may not have issues associated with the condition though most are developmentally delayed and only about 50% undergo puberty normally.
• 48, XXYY (also known as XXYY syndrome) - A condition that describes a male with one extra female chromosome and one extra male chromosome. It occurs in 1 in 18,000 to 40,000 male births.^[9] 48, XXYY may result in infertility, low testosterone, and neurodevelopmental disorders like ADHD or autism but some men have no issues.
• 49, XXXXX (also known as pentasomy X and XXXXX syndrome) - A condition that describes a female with three extra female chromosomes. It is considered a variant of Triple X syndrome. Women with 49, XXXXX usually suffer from numerous health issues such as patent ductus arteriosus, scoliosis, kidney hypoplasia, and abnormal lobulation of the lungs. Physical deformities include microcephaly, micrognathia, and webbing of the neck.
• 49, XXXXY - A condition that describes a male with three extra female chromosomes. It is rare, occurring in 1 in 85,000 to 100,000 males.^[10][11] It is considered a variation of Klinefelter syndrome. Men with 49, XXXXY syndrome often suffer from mental retardation.
• 5α-reductase deficiency (also known as 5-ARD) - An autosomal recessive condition caused by a mutation of the 5-alpha reductase type 2 gene. It only affects people with Y chromosomes, namely genetic males. People with this condition are fertile, with the ability to father children, but may be raised as females due to amibiguous or feminized genitalia.
• 17β-Hydroxysteroid dehydrogenase deficiency - A condition characterized by impaired androgen and estrogen synthesis in males and females, respectively. Results in pseudohermaphroditism/undervirilization in males and in excessive virilization of adult females.
• Androgen insensitivity syndrome (also known as AIS) - A condition which affects a genetic male's virilization. A man with androgen insensitivity syndrome produces androgens and testosterone but their body does not recognize it, either partially or completely. Mild androgen insensitivity syndrome generally causes no developmental issues and people with this form are raised as males. Partial androgen insensitivity syndrome results in ambiguous genitalia and there is no consensus regarding whether to raise a child with this form as male or female. Complete androgen insensitivity syndrome causes a genetic male to have a vagina (often incompletely developed, nearly always blind-ending), breasts, and a clitoris and people with this form are raised as females.
• Aphallia - A rare occurrence where a male is born without a penis or where a female is born without a clitoris. As of 2005, only 75 cases of aphallia have been documented.^[12] It should not be confused with intentional or accidental amputation of the genitalia.
• Aposthia - A congenital defect where a male is born without a foreskin.
• Aromatase deficiency - A disorder in which, in females, is characterized by androgen excess and estrogen deficiency, and can result in inappropriate virilization, though without pseudohermaphroditism (i.e., genitals are phenotypically appropriate) (with the exception of the possible incidence of clitoromegaly).
• Aromatase excess syndrome (also known as familial hyperestrogenism) - A condition that causes excessive estrogen production, resulting in feminization without pseudohermaphroditism (i.e., male genitalia at birth and female secondary sexual characteristics at puberty) in males and hyperfeminization in females.
• Clitoromegaly - A clitoris that is considered larger than average. While clitoromegaly may be a symptom of an intersex condition, it may also be considered a normal variation in clitoris size. Clitoromegaly causes no health issues. Surgical reduction of the clitoris or its complete removal may be performed to normalize the appearance of the genitalia. While female genital mutilation is outlawed in many countries, reduction or the removal of the clitoris in cases of clitoromegaly are generally exempt, despite the fact that it is a nontherapeutic and sexually damaging surgery. Clitoromegaly may also be caused by females using testosterone or anabolic steroids for purposes related to female to male gender transition or bodybuilding.
• Combined 17α-hydroxylase/17,20-lyase deficiency - A condition in which presents as a combination of the symptoms of congenital adrenal hyperplasia and isolated 17,20-lyase deficiency. See those two conditions for more information.
• Complete androgen insensitivity syndrome (also known as CAIS) - A condition which completely affects a genetic male's ability to recognize androgens. It is considered a form of androgen insensitivity syndrome and is the most severe form. People with complete androgen insensitivity are raised as females and usually do not discover they are genetic males until they experience amenorrhoea in their late teens or they need medical intervention due to a hernia caused by their undescended testes. Complete androgen insensitivity syndrome results in a genetic male having a vagina, clitoris, and breasts which are capable of breastfeeding. However, they will not have ovaries or a uterus. Because they do not have ovaries or sufficiently developed testicles, people with complete androgen insensitivity syndrome are infertile.
• Congenital adrenal hyperplasia (also known as CAH) - A condition that causes excessive androgen production, which causes excessive virilization. It is most problematic in genetic females, where severe virilization can result in her having vaginal agenesis (absence of vagina) and a functional penis which is capable of penetrative intercourse. Females with this condition are usually fertile, with the ability to become pregnant and give birth. The salt-wasting variety of this condition is fatal in infants if left untreated.
• Diphallia (also known as penile duplication, diphallic terata, and diphallasparatus) - A condition where a male is born with two penises. It's extremely rare, with only 100 cases being recorded since 1609 and an occurrence rate of 1 in 5,500,000 in the United States. The penises may be side by side or one on top of the other, being of equal size or with one penis being distinctively larger than the other, and both penises may be suitable for urination and intercourse. Men with diphallia may be sterile.
• Estrogen insensitivity syndrome (EIS) - The estrogen counterpart to androgen insensitivity syndrome. Extremely rare, with only one verified case having been reported; a biological male presented with tall stature, a heightened risk of osteoporosis, and sterility.
• Gonadal Dysgenesis - is any congenital developmental disorder of the reproductive system characterized by a progressive loss of primordial germ cells on the developing gonads of an embryo.
• Isolated 17,20-lyase deficiency - A condition that is characterized by an either partial or complete inability to produce androgens and estrogens. Results in partial or complete feminization and undervirilization in males and in a delayed, reduced, or absent puberty in both sexes, in turn causing sexual infantilism and infertility, among other symptoms.
• Klinefelter syndrome (also known as 47, XXY and XXY syndrome) - A condition that describes a male born with at least one extra female chromosome. Though the most common variation is 47, XXY, a man may also be 48, XXXY or 49, XXXXY. It is a common occurrence, affecting 1 in 500 to 1,000 men.^[13] While some men may have no issues related to the syndrome, some may experience gynecomastia, micropenis, cognitive difficulties, hypogonadism, reduced fertility/infertility, and/or little or no facial hair. Testosterone therapy may be pursued by men who desire a more masculine appearance and those with gynecomastia may opt to undergo a reduction mammoplasty. Men who wish to father children may be able to do so with the help of IVF.^[14]
• Leydig cell hypoplasia - A condition solely affecting biological males which is characterized by a partial or complete inactivation of the luteinizing hormone receptor, resulting in stymied androgen production. Patients may present at birth with a fully female phenotype, ambiguous genitalia, or only mild genital defects such as micropenis and hypospadias. Upon puberty, sexual development is either impaired or fully absent.
• Micropenis (also known as microphallus) - A penis that measures 3 inches (7.62 centimeters) or less in length when erect. It is a common condition, occurring in 1 in 200 men.^[15] Micropenis may be the result of undervirilization during fetal development or may be caused by an underlying intersex condition, such as mild androgen insensitivity syndrome, partial androgen insensitivity syndrome, or Klinefelter syndrome. It may also be considered a natural variation of penis size. While the majority of men have no issues with having a micropenis, some may opt to use a prosthetic penis or undergo penile enlargement to increase the size of their penis.
• Mild androgen insensitivity syndrome (also known as MAIS) - A condition which mildly affects a genetic male's ability to recognize androgens. It is considered a form of androgen insensitivity syndrome and is considered the least severe form. While men generally do not need any specialized medical care related to this form, mild androgen insensitivity syndrome may result in gynecomastia and hypospadias. Neither gynecomastia nor hypospadias require surgerical intervention or adversely affect a man's health though some men may opt to undergo surgery to remove their breasts and/or repair their hypospadias. Men with mild androgen insensitivity syndrome may have reduced fertility.
• Mixed gonadal dysgenesis - is a condition of unusual and asymmetrical gonadal development leading to an unassigned sex differentiation. A number of differences have been reported in the karyotype, most commonly a mosaicism 45,X/ 46, XY.
• Partial androgen insensitivity syndrome (also known as PAIS) - A condition which partially affects a genetic male's ability to recognize androgens. It is considered a form of androgen insensitivity syndrome and while it is not as severe as complete androgen insensitivity syndrome, it is more severe than mild androgen insensitivity syndrome. Partial androgen insensitivity syndrome causes major problems with gender assignment because it causes ambiguous genitalia such as a micropenis or clitoromegaly in addition to breast development. People with partial androgen insensitivity syndrome who are assigned as males may undergo testosterone therapy to virilize their body while those who are assigned as females may undergo surgical reduction of the clitoris and/ or estrogen therapy.
• Pseudovaginal perineoscrotal hypospadias (also known as PPSH) - A form of ambiguous genitalia which results in a phallic structure that is smaller than a penis but larger than a clitoris, a chordee, hypospadias, and a shallow vagina.
• Swyer Syndrome (Also known as Pure Gonadal Dysgenesis or XY gonadal dysgenesis) is a type of hypogonadism in a person whose karyotype is 46,XY. The person is externally female with streak gonads, and left untreated, will not experience puberty. Such gonads are typically surgically removed (as they have a significant risk of developing tumors) and a typical medical treatment would include hormone replacement therapy with female hormones.
• Triple X syndrome - A condition that describes a female born with an extra female chromosome, making her karotype 47, XXX. It is a common occurrence, affecting 1 in 1,000 females.^[16] It generally causes no health issues or abnormal development.
• Turner syndrome (also known as Ullrich-Turner syndrome and gonadal dysgenesis) - A condition that describes a female born without a female chromosome or with an abnormal female chromosome, making her karotype 45, XO. It occurs in 1 in 2,000 to 5,000 females. Turner syndrome causes numerous health and development problems, including but not limited to short stature, lymphedema, infertility, webbed neck, coarctation of the aorta, ADHD, amenorrhoea, and obesity.
• Uterus didelphys (also known as double uterus) - A condition where a female is born with two uteri. It is often accompanied by two vaginas. It is generally not considered a health issue and women with uterus didelphys usually have normal sex lives and pregnancies.^[17]

Controversy

The term DSD (and particularly its association with medical disorders) has been controversial. The argument over terminology reflects a deeper disagreement over the extent to which intersex conditions require medical intervention, the appropriateness of certain interventions, and whether physicians and parents should make irreversible treatment decisions on behalf of young children if the DSD is not life-threatening.

• In the past the term "hermaphrodite" was sometimes erroneously used to describe people with intersex/DSD conditions. This term is no longer used to describe humans (or any other mammals). The correct technical definition of a hermaphrodite is a single organism that has complete sets of both male and female sexual organs, as is the case with most trees and flowering plants.
• Lee et al. in a 2006 Consensus statement on management of intersex disorders proposed a system of nomenclature based on "disorders of sex development" for clinical use, suggesting that "terms such as intersex, pseudohermaphroditism, hermaphroditism, sex reversal, and gender based diagnostic labels are particularly controversial," may be perceived as pejorative, and are confusing to practitioners and parents alike.
• Use of the term disorder of sex development (DSD) is controversial among many activists and community organisations.^[18][19][20] Many governments and international institutions use the term 'intersex' in preference to 'DSD'.
• In "We Used to Call Them Hermaphrodites," Eric Vilain states that "DSD" is not a synonym for intersex; he states that it replaces medical terms based on "hermaphrodite".^[21]
• A committee of the Senate of Australia found that labelling intersex as "pejorative" appeared to be a post-hoc rationalisation in the 2006 Consensus statement.
• Academics like Georgiann Davis and Morgan Holmes, and clinical psychologists like Tiger Devore argue that the term DSD was designed to "reinstitutionalise" medical authority over intersex bodies, making intersex bodies more treatable and more of a stigma.^{[18][22][23][24]}
• In a 2013 paper on Preimplantation genetic diagnosis and "intersex conditions" Professor Jeff Nisker describes how, "Once a difference becomes a medical disorder to which the medical profession is dedicating time and resources to prevent, procedures to this end become endowed with appropriateness"^[25] In the same journal, Georgiann Davis references "intersex traits".^[26]

Academic and community responses to the controversy

Morgan Holmes argues that the replacement of the word 'intersex' with 'Disorders of sex development' in clinical settings "reinstitutionalises clinical power to delineate and silence those marked by the diagnosis" and "that this silencing is precisely the point of the new terminology."^[24] Writing in Advances in Medical Sociology, Georgiann Davis described how:

Medical professionals needed to maintain their authority in the face of intersex activism, and they did so linguistically through a reinvention of the intersex diagnosis. The new DSD terminology constructs "sex" as a scientific phenomenon, and a binary one at that...This places intersexuality neatly into medical turf and safely away from critics of its medicalisation.^[22][23]

In a series of articles on Preimplantation genetic diagnosis in The American Journal of Bioethics in 2013, bioethicists and related authors reference "intersex traits" or "intersex conditions". Professor Jeff Nisker describes how:

I began laboratory research on PGD in 1989 to offer an option to Canadian women already undergoing in vitro fertilization (IVF) who carried a gene for a “severe” genetic condition and planned to undergo amniocentesis. However, when our study moved from “the mouse to the human” in 1993 and the press pounced, many couples with no indication for IVF and no inherited risk called my office requesting PGD. The most frequent genetic condition they desired to prevent was XX (they wanted a boy)…

Once a difference becomes a medical disorder to which the medical profession is dedicating time and resources to prevent, procedures to this end become endowed with appropriateness.^[25]

On 28 April 2014, the British Medical Journal published an article by Associate Professor Rebecca Jordan-Young, Emeritus Professor Peter Sönksen, and scholar Katrina Karkazis referencing "women with intersex conditions".^[3]

Alternatives have been offered: Milton Diamond has suggested the use of "variation"^[27][28] or of "difference",^[29] and Elizabeth Reis has suggested "divergence";^[30] the latter two suggestions would retain the initial D in DSD.

Governmental and institutional responses to the controversy

In an October 2013 report of a Parliamentary inquiry into the Involuntary or coerced sterilisation of intersex people in Australia, the Australian Senate's Community Affairs References Committee recommended a review of clinical use of the term.^[22] A similar rejection of 'Disorders of Sex Development' was adopted elsewhere in Australia in decision-making guidelines, Decision-making principles for the care of infants, children and adolescents with intersex conditions, published in February 2013 by the Department of Health of the State of Victoria.^[31]

Australia has also enacted anti-discrimination legislation that includes the attribute "intersex status"^[32][33] and published identity recognition guidelines available to intersex and other people.^[34]

In May 2014, the World Health Organization issued a joint statement on Eliminating forced, coercive and otherwise involuntary sterilization, An interagency statement with the OHCHR, UN Women, UNAIDS, UNDP, UNFPA and UNICEF. The report references the involuntary surgical "sex-normalising or other procedures" on "intersex persons". The report recommends a range of guiding principles for medical treatment, including ensuring patient autonomy in decision-making, ensuring non-discrimination, accountability and access to remedies.^[35]

During 2015, the Council of Europe,^[4] and Inter-American Commission on Human Rights^[5] have called for a review of medical classifications that unnecessarily medicalize intersex traits^[4][5][6] an end to medical interventions without consent, and improved disclosure. the European Union Agency for Fundamental Rights^[6] and UN Treaty Bodies have called for consent by individuals subjected to medical treatment, and improved disclosure.^[36][37]

See also

• Intersex
• Intersex human rights
• Pseudohermaphroditism, and ambiguous genitalia
• Congenital anomalies of the genitalia
• Inborn errors of steroid metabolism
• Hypogonadism (hypoandrogenism and hypoestrogenism)
• Hypergonadism (hyperandrogenism and hyperestrogenism)
• Delayed puberty and precocious puberty
• Sex hormone (androgen and estrogen)
• GnRH and gonadotropin (FSH and LH)
• Fixing Sex: Intersex, Medical Authority, and Lived Experience

References

External links

• Disorders of Sex Development Research Website provides information regarding the causes, frequency and implications of DSD, in plain language, from a genetics and biology research perspective. It also includes detailed scientific and medical information for clinicians and scientists who work with children, adolescents and adults affected by DSD or intersex, or analyse the genetic causes.
• Accord Alliance Promoting comprehensive and integrated approaches to care that enhance the health and well-being of people and families affected by DSD by fostering collaboration among all stakeholders.
• YourChild: Disorders of Sex Development (DSD) Resources University of Michigan Health System.
• Sex Development: An Overview Animation of prenatal genital development from The Hospital for Sick Children, Toronto.
• Handbook for Parents Consortium on the Management of Disorders of Sex Development.
• Clinical Guidelines for the Management of Disorders of Sex Development in Childhood Consortium on the Management of Disorders of Sex Development.

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