Abstract
The treatment and care of individuals who have a difference of sex development (DSD) have been revised over the past two decades and new guidelines have been published. In order to study the impact of treatments and new forms of management in these rare and heterogeneous conditions, standardised assessment procedures across centres are needed. Diagnostic work-up and detailed genital phenotyping are crucial at first assessment. DSDs may affect general health, have associated features or lead to comorbidities which may only be observed through lifelong follow-up. The impact of medical treatments and surgical (non-) interventions warrants special attention in the context of critical review of current and future care. It is equally important to explore gender development early and refer to specialised services if needed. DSDs and the medical, psychological, cultural and familial ways of dealing with it may affect self-perception, self-esteem, and psychosexual function. Therefore, psychosocial support has become one of the cornerstones in the multidisciplinary management of DSD, but its impact remains to be assessed. Careful clinical evaluation and pooled data reporting in a global DSD registry will allow linking genetic, metabolomic, phenotypic and psychological data. For this purpose, our group of clinical experts and patient and parent representatives designed a template for structured longitudinal follow-up. In this paper, we explain the rationale behind the selection of the dataset. This tool provides guidance to professionals caring for individuals with a DSD and their families. At the same time, it collects the data needed for answering unsolved questions of patients, clinicians, and researchers. Ultimately, outcomes for defined subgroups of rare DSD conditions should be studied through large collaborative endeavours using a common protocol.
Introduction
The term differences (disorders) of sex development (DSD) refers to a heterogeneous group of conditions that affect the urogenital tract and result in atypical sex development. The prevalence of the individual conditions is mostly very low and only a small fraction of all conditions characterised by variations in sex characteristics pose major clinical challenges and/or require multidisciplinary care (1). Recent outcome studies suggest that having a DSD may impact an individuals’ health status and psychological well-being in every stage of life (2, 3, 4), though physical or psychological comorbidities have been rarely studied in detail, especially in adults. Influencing factors include the rarity of the respective conditions, individual drawbacks to participate in medical studies and the dispersion of affected individuals over decentralised health care structures, with frequent loss of patients for follow-up. In addition, the quality of care for individuals with a DSD varies considerably across Europe, between centres and within diagnostic groups. Patient satisfaction with care is lowest amongst individuals with the rarest conditions (5).
The development of a concrete and evidence-based protocol for structured review and clinical data collection in children and adults who have a DSD, at various age intervals, may be pivotal in addressing these difficulties (6) (Fig. 1). It minimises bias in clinical assessments and can provide guidance to clinicians who do not regularly see these patients. In fact, there is a need to support health care professionals in assessing a small amount of data regularly as part of a holistic routine clinical care. Equally important, it enables exchange of data amongst clinical centres and in research networks such as the international DSD Registry I-DSD (https://www.i-dsd.org), allowing large-scale multicentre studies. For patients, it can increase understanding of their condition, provide clarity about one’s future medical needs, enhance compliance and facilitate discussions with caregivers (7). From a healthcare point of view, adherence to an evidence-based assessment protocol can serve as a quality indicator and benchmarking tool (8).
Schema of the longitudinal I-DSD registration tool showing time points, ages for data entry, starting at the age of diagnosis. Neonatal data, including genetic information if available, should always be entered regardless of the age at diagnosis.
Citation: European Journal of Endocrinology 181, 5; 10.1530/EJE-19-0363
Schema of the longitudinal I-DSD registration tool showing time points, ages for data entry, starting at the age of diagnosis. Neonatal data, including genetic information if available, should always be entered regardless of the age at diagnosis.
Citation: European Journal of Endocrinology 181, 5; 10.1530/EJE-19-0363
Schema of the longitudinal I-DSD registration tool showing time points, ages for data entry, starting at the age of diagnosis. Neonatal data, including genetic information if available, should always be entered regardless of the age at diagnosis.
Citation: European Journal of Endocrinology 181, 5; 10.1530/EJE-19-0363
Several aspects of DSD management are surrounded by controversy or uncertainty and have led to a thorough revision of clinical practice in recent years (1). For example, genital surgery in young children is more often avoided nowadays in order to protect childrens’ rights of an open future and integrity of the body; and increasing numbers of children grow up with atypical-looking genitalia, of which the psychological impact is not known (9). Many DSD teams provide psychological support to affected families as a standard component of care nowadays, children are informed early about their condition, and gender issues are openly discussed (6). Some teams include peer support in the medical management plan (10). Structured longitudinal assessment of individuals with a DSD across centres may provide future evidence in favour or against these new practices, with specific relevance to (rare) individual diagnoses, provided that all relevant parameters are considered in parallel and by standardised measurement tools.
In accordance with patient aspirations, the promotion of a standardised protocol that uses a non-binary vocabulary and medical approach can be paramount in inducing societal change as well as amongst the medical community, in attitudes towards gender perception and normative paradigms of sex, including genital characteristics (11). This will by itself be instrumental in defining the place, timing and the specific medical need of genital surgery.
Development of consensus on standardised data collection
The development of a meaningful, holistic schedule for clinical assessment that allows for standardised longitudinal data collection over time in individuals who have a DSD has been the primary goal of an expert multidisciplinary working group, including representatives from patient support groups. This group operated in the period 2013–2017 in the framework of the European Cooperation in Science and Technology (COST) Action BM1303 “DSDnet” (www.DSDnet.eu), funded by the European Union Horizon 2020 programme. Collaboratively, the group (1) reviewed the literature on existing instruments for clinical phenotyping at all ages; (2) defined their major strengths and shortcomings as well as hitherto insufficiently covered areas of (para)medical attention; and (3) discussed essential characteristics of a qualitative longitudinal follow-up programme until agreement was reached on a protocol for standardised assessment at various ages that was versatile enough to be used in clinical settings as well as within electronic global platforms such as the I-DSD Registry.
General dataset and ages at which follow-up assessments are recommended
Criteria for referral of a child for expert evaluation are specified in the UK guidelines (12). At first referral, linking the case to original health records and obtaining consent for sharing data (local, national, international) are crucial. Basic DSD-related information, such as diagnosis, karyotype, birth-assigned sex, and social gender should also be included (Table 1). Thereafter, appropriate time intervals for clinical revision of patients depend on the respective conditions, patient age, and individual circumstances. However, for registration and research purposes, it was considered crucial to standardise a minimal set of time points, corresponding to important developmental milestones, at which relevant clinical data should be collected (Fig. 1).
Neonatal assessment (within first month of birth).
| Parameters | Units/ options | Parameters | Units/ options |
|---|---|---|---|
| General | Surgery | ||
| Date of Assessment | dd/mm/yyyy | Left Gonad Biopsy | Yes/ No/ Not known |
| Age at Assessment | years | Right Gonad Biopsy | Yes/ No/ Not known |
| Gestational Age | weeks | Left Gonadectomy | Yes/ No/ Not known |
| Birth Weight | g | Right Gonadectomy | Yes/ No/ Not known |
| Birth Length | cm | Genital reconstructive surgery** | None/ clitoral surgery / vaginal surgery / labioscrotal surgery / hypospadias surgery / urethral surgery other than hypospadias; age |
| Birth Head Circumference | cm | Reasons for genital reconstructive surgery | Functional / cosmesis / both |
| Weight | kg | Post Surgical Complications | Yes/ No/ Not known; if yes, describe. |
| Height | cm | Psychosocial | |
| BMI | kg/m2 | Change in Legal Sex | Yes/ No/ Not known |
| Mothers Height | cm | Psychosocial Support Offered to Parents | Yes/ No/ Not known |
| Fathers Height | cm | Ongoing Psychosocial Support | Yes/ No/ Not known |
| Mid Parental Height | cm | ||
| Original Sex Assigned | Male/ Female/ Both/ Not assigned/ Other | Medication | |
| Current Gender | Male/ Female/ Both/ Not assigned/ Other | Testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Child raised as | Male/ Female/ Both / Other | Oestrogen | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Associated Conditions* | DHT | Yes (IM, Oral, Transdermal)/ No/ Not known | |
| Known Syndrome | Yes/ No | Aromatase Inhibitor | Yes/ No/ Not known |
| External Phenotype | GnRH analogues | Yes/ No/ Not known | |
| Meatus | Typical female/ Perineal/ Scrotal/ Penoscrotal/ Penile/ Coronal/ Typical male | Glucocorticoids | Yes/ No/ Not known |
| Left Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | Fludrocortisone | Yes/ No/ Not known |
| Right Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | Other drugs | Yes/ No/ Not known |
| Genital Tubercle Length | <10/ 10-20/ 21-25/ 26-30/ >30 mm | Lab Tests | |
| Phallus Size | Within/ Below/ Above the reference range for male; Within/ Below/ Above the reference range for female | LH | Low/ Normal/ High/ Not known |
| Labioscrotal Fusion | Yes/ No | FSH | Low/ Normal/ High/ Not known |
| Anogenital Distance 1# (AGD1) | mm | AMH | Low/ Normal/ High/ Not known |
| Anogenital Distance 2## (AGD2), | mm | Inhibin B | Low/ Normal/ High/ Not known |
| External Masculinisation Score (EMS) | Androstenedione | Low/ Normal/ High/ Not known | |
| External Genitalia Score (EGS) | Total Testosterone | Low/ Normal/ High/ Not known | |
| Internal Phenotype | Free Testosterone | Low/ Normal/ High/ Not known | |
| Imaging Modality- Left Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Dihydrotestosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Oestradiol | Low/ Normal/ High/ Not known |
| Left Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | 17-OHP | Low/ Normal/ High/ Not known |
| Right Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | Urine steroids | Normal/ Abnormal |
| Imaging Modality- Uterus | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | hCG Stimulation Test | Specify protocol |
| Uterus Morphology | Absent/ Müllerian remnants/ rudimentary/ Normal/ Not known | Adrenal Stimulation Test | Specify protocol |
| Imaging Modality- Left Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | 11-deoxycortisol | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Pregnenolone | Low/ Normal/ High/ Not known |
| Left Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | 17-OH Pregnenolone | Low/ Normal/ High/ Not known |
| Right Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | DHEA | Low/ Normal/ High/ Not known |
| Distance- Vaginal Confluence to Bladder Neck | cm | ||
| Distance- Vaginal Confluence to Introitus | cm | ||
| Imaging Modality- Left Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | ||
| Imaging Modality- Right Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | ||
| Left Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known | ||
| Right Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known |
*Associated conditions: CNS, heart, renal, skeletal, skin, ENT, eyes, blood and lymph, craniofacial, adrenal, GI tract, haematological, respiratory, SGA (small for gestational age), short stature, non-defined syndrome, other. **Genital reconstructive surgery field may be repeated.
# AGD 1: Distance from the centre of the anus to the posterior base of the labioscrotal folds; ##AGD 2: Distance from the centre of the anus to the anterior base of the phallus.
A summary of neonatal data, where available, should be collected in all cases with later presentation (Table 2). Clinical revision at age 4 years (Table 3) allows for comprehensive assessment of psychological developmental milestones, associated symptoms, and growth patterns, including catch-up growth. The process of informing the child about the condition should start as soon as possible after diagnosis, along with the provision of support in acquiring a vocabulary to talk about the DSD (13). Practical advice on this matter can be found at support group resources (e.g. www.dsdfamilies.org or https://www.iglyo.com/wp-content/uploads/2018/10/Supporting-Your-Intersex-Child.pdf). At age 8 years (Table 3), relevant information on growth and development shortly before start of puberty can be obtained. At this age the child understands more complex information about how the body functions and about the specific DSD. Gender identity or eventual dysphoria may be ascertained and children experiencing uncertainty can be referred for expert psychological or psychiatric evaluation and support. Pubertal development and progression (Table 4) may be compromised in many children who have a DSD. Some children may need hormonal induction of puberty. Standardised assessment at the start of puberty and the outcome of pubertal development are therefore paramount to document, though most children will need clinical revision more frequently. Transition to adult healthcare should be discussed early on during this period (8, 14).
Clinical assessment (at any age if first assessment after 1 month of age).
| Parameters | Units/ options | Parameters | Units/ options |
|---|---|---|---|
| General | Surgery | ||
| Date of Assessment | dd/mm/yyyy | Left Gonad Biopsy | Yes/ No/ Not known |
| Age at Assessment | years | Right Gonad Biopsy | Yes/ No/ Not known |
| Gestational Age | weeks | Left Gonadectomy | Yes/ No/ Not known |
| Birth Weight | g | Right Gonadectomy | Yes/ No/ Not known |
| Birth Length | cm | Genital reconstructive surgery** | None/ clitoral surgery / vaginal surgery / labioscrotal surgery / hypospadias surgery / urethral surgery other than hypospadias; age |
| Birth Head Circumference | cm | Reasons for genital reconstructive surgery | Functional / cosmesis / both |
| Weight | kg | Post Surgical Complications | Yes/ No/ Not known; if yes, describe. |
| Height | cm | Psychosocial | |
| BMI | kg/m2 | Change in Legal Sex | Yes/ No/ Not known |
| Mothers Height | cm | Psychosocial Support Offered to Parents | Yes/ No/ Not known |
| Fathers Height | cm | Ongoing Psychosocial Support | Yes/ No/ Not known |
| Mid parental height | cm | ||
| Original Sex Assigned | Male/ Female/ Both/ Not assigned/ Other | Medication | |
| Current Gender | Male/ Female/ Both/ Not assigned/ Other | Testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Child raised as | Male/ Female/ Both / Other | Oestrogen | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Associated Conditions* | DHT | Yes (IM, Oral, Transdermal)/ No/ Not known | |
| Known Syndrome | Yes/ No | Aromatase Inhibitor | Yes/ No/ Not known |
| External Phenotype | GnRH analogues | Yes/ No/ Not known | |
| Meatus | Typical female/ Perineal/ Scrotal/ Penoscrotal/ Penile/ Coronal/ Typical male | Glucocorticoids | Yes/ No/ Not known |
| Left Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | Fludrocortisone | Yes/ No/ Not known |
| Right Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | Other drugs | Yes/ No/ Not known |
| Genital Tubercle Length | <10/ 10-20/ 21-25/ 26-30/ >30 mm | Lab Tests | |
| Phallus Size | Within/ Below/ Above the reference range for male; Within/ Below/ Above the reference range for female | LH | Low/ Normal/ High/ Not known |
| Labioscrotal Fusion | Yes/ No | FSH | Low/ Normal/ High/ Not known |
| Anogenital Distance 1# (AGD1) | mm | AMH | Low/ Normal/ High/ Not known |
| Anogenital Distance 2## (AGD2), | mm | Inhibin B | Low/ Normal/ High/ Not known |
| External Masculinisation Score (EMS) | Androstenedione | Low/ Normal/ High/ Not known | |
| External Genitalia Score (EGS) | Total Testosterone | Low/ Normal/ High/ Not known | |
| Internal Phenotype | Free Testosterone | Low/ Normal/ High/ Not known | |
| Imaging Modality- Left Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Dihydrotestosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Oestradiol | Low/ Normal/ High/ Not known |
| Left Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | 17-OHP | Low/ Normal/ High/ Not known |
| Right Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | Urine steroids | Normal/ Abnormal |
| Imaging Modality- Uterus | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | hCG Stimulation Test | Specify protocol |
| Uterus Morphology | Absent/ Müllerian remnants/ rudimentary/ Normal/ Not known | Adrenal Stimulation Test | Specify protocol |
| Imaging Modality- Left Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | 11-deoxycortisol | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Pregnenolone | Low/ Normal/ High/ Not known |
| Left Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | 17-OH Pregnenolone | Low/ Normal/ High/ Not known |
| Right Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | DHEA | Low/ Normal/ High/ Not known |
| Distance- Vaginal Confluence to Bladder Neck | cm | ||
| Distance- Vaginal Confluence to Introitus | cm | ||
| Imaging Modality- Left Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | ||
| Imaging Modality- Right Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | ||
| Left Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known | ||
| Right Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known |
*Associated conditions: CNS, Heart, Renal, Skeletal, Skin, ENT, Eyes, Blood and Lymp, Craniofacial, Adrenal, GI Tract, Haematological, Respiratory, SGA (Small for Gestational Age), Short stature, Non-defined syndrome, Other. **Genital reconstructive surgery field may be repeated.
#AGD 1: Distance from the centre of the anus to the posterior base of the labioscrotal folds; ##AGD 2: Distance from the centre of the anus to the anterior base of the phallus
Childhood assessment (at age 4 years and 8 years)
| Parameters | Units/options | Parameters | Units/options |
|---|---|---|---|
| General | Surgery | ||
| Date of Assessment | dd/mm/yyyy | Left Gonad Biopsy | Yes/ No/ Not known |
| Age at Assessment | years | Right Gonad Biopsy | Yes/ No/ Not known |
| Weight | kg | Left Gonadectomy | Yes/ No/ Not known |
| Height | cm | Right Gonadectomy | Yes/ No/ Not known |
| BMI | kg/m2 | Genital reconstructive surgery** | None/ clitoral surgery / vaginal surgery / labioscrotal surgery / hypospadias surgery / urethral surgery other than hypospadias; age |
| Mothers Height | cm | Reasons for genital reconstructive surgery | Functional / cosmesis / both |
| Fathers Height | cm | Post Surgical Complications | Yes/ No/ Not known; if yes, describe. |
| Mid parental height | cm | ||
| Original Sex Assigned | Male/ Female/ Both/ Not assigned/ Other | Psychosocial, Gender Identity | |
| Current Gender | Male/ Female/ Both/ Not assigned/ Other | Any Change in Legal Sex | Yes/ No/ Not known |
| Child raised as | Male/ Female/ Both / Other | Psychosocial Support Offered to Parents | Yes/ No/ Not known |
| Associated Conditions* | Ongoing Psychosocial Support for parents | Yes/ No/ Not known | |
| Known Syndrome | Yes/ No | Psychosocial Support Offered to Child | Yes/ No/ Not known |
| Bone age | Ongoing Psychosocial Support for Child | Yes/ No/ Not known | |
| Bone Age date | dd/mm/yyyy | Age-appropriate Information to Child | Yes/ No/ Not known |
| Bone age result | years | Has Child Questioned Their Gender | Yes/ No/ Not known |
| Bone age method | TW20/ Radius-ulna-short bone/ Greulich & Pyle | Is Child Distressed About Gender Identity or Assignment | Yes/ No/ Not known |
| External Phenotype | Medication | ||
| Meatus | Typical female/ Perineal/ Scrotal/ Penoscrotal/ Penile/ Coronal/ Typical male | Testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Left Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | Oestrogen | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Right Gonad Location | Impalpable/ Inguinal/ Inguinoscrotal/ Labioscrotal | DHT | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Genital Tubercle Length, | <10/ 10-20/ 21-25/ 26-30/ >30 mm | Aromatase Inhibitor | Yes/ No/ Not known |
| Phallus Size | Within/ Below/ Above the reference range for male; Within/ Below/ Above the reference range for female | GnRH analogues | Yes/ No/ Not known |
| Labioscrotal Fusion | Yes/ No | Glucocorticoids | Yes/ No/ Not known |
| External Masculinisation Score (EMS) | Fludrocortisone | Yes/ No/ Not known | |
| External Genitalia Score (EGS) | Other drugs | Yes/ No/ Not known | |
| Internal Phenotype | Lab Tests | ||
| Imaging Modality- Left Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | LH | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Gonad | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | FSH | Low/ Normal/ High/ Not known |
| Left Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | AMH | Low/ Normal/ High/ Not known |
| Right Gonad Morphology | Absent/ Streak/ Testis/ Ovary/ Ovotestis/ Other | Inhibin B | Low/ Normal/ High/ Not known |
| Imaging Modality- Uterus | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Androstenedione | Low/ Normal/ High/ Not known |
| Uterus Morphology | Absent/ Müllerian remnants/ rudimentary/ Normal/ Not known | Total Testosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Left Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Free Testosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Right Fallopian Tube | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Dihydrotestosterone | Low/ Normal/ High/ Not known |
| Left Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | Oestradiol | Low/ Normal/ High/ Not known |
| Right Fallopian Tube Morphology | Absent/ Rudimentary/ Normal/ Not known | 17-OHP | Low/ Normal/ High/ Not known |
| Distance- Vaginal Confluence to Bladder Neck | cm | Urine steroids | Normal/ Abnormal |
| Distance- Vaginal Confluence to Introitus | cm | hCG Stimulation Test | Specify protocol |
| Imaging Modality- Left Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Adrenal Stimulation Test | Specify protocol |
| Imaging Modality- Right Vas Deferens | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | 11-deoxycortisol | Low/ Normal/ High/ Not known |
| Left Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known | Pregnenolone | Low/ Normal/ High/ Not known |
| Right Vas Deferens Morphology | Absent/ Rudimentary/ Normal/ Not known | 17-OH Pregnenolone | Low/ Normal/ High/ Not known |
| DHEA | Low/ Normal/ High/ Not known |
*Associated conditions: CNS, Heart, Renal, Skeletal, Skin, ENT, Eyes, Blood and Lymp, Craniofacial, Adrenal, GI Tract, Haematological, Respiratory, SGA (Small for Gestational Age), Short stature, Non-defined syndrome, Other. ** Genital reconstructive surgery field may be repeated.
Adolescent assessment (at start of puberty and end of puberty)
| Parameters | Units/ options | Parameters | Units/ options |
|---|---|---|---|
| General | Surgery | ||
| Date of Assessment | dd/mm/yyyy | Left Gonad Biopsy | Yes/ No/ Not known |
| Age at Assessment | years | Right Gonad Biopsy | Yes/ No/ Not known |
| Weight | kg | Left Gonadectomy | Yes/ No/ Not known |
| Height | cm | Right Gonadectomy | Yes/ No/ Not known |
| BMI | kg/m2 | Genital reconstructive surgery** | None/ clitoral surgery / vaginal surgery / labioscrotal surgery / hypospadias surgery / urethral surgery other than hypospadias/ phalloplasty; age |
| Mothers Height | cm | Vaginal Hypoplasia | Yes / No/ Not known |
| Fathers Height | cm | Medical management of vaginal hypoplasia | Dilation / Surgery / None |
| Mid parental height | cm | Type of Vaginoplasty | Intestinal / Peritoneal / Davydov / Vecchietti / Baloon / Other |
| Original Sex Assigned | Male/ Female/ Both/ Not assigned/ Other | Post Surgical Complications | Yes/ No/ Not known; if yes, describe. |
| Current Gender | Male/ Female/ Both/ Not assigned/ Other | Gonadal Germ Cell Cancer | Yes/ No/ Not known |
| Adolescent raised as | Male/ Female/ Both / Other | Left Gonad | None/ GCNIS/ Gonadoblastoma/ Seminoma/ Non-seminoma/ Dysgerminoma/ Other |
| Associated Conditions* | Right Gonad | None/ GCNIS/ Gonadoblastoma/ Seminoma/ Non-seminoma/ Dysgerminoma/ Other | |
| Known Syndrome | Yes/ No | Psychosocial, Gender Identity | |
| Bone age, bone mineral density | Change in Legal Sex | Yes/ No/ Not known | |
| Bone Age date | dd/mm/yyyy | Psychosocial Support Offered for Parents | Yes/ No/ Not known |
| Bone age result | years | Ongoing Psychosocial Support for parents | Yes/ No/ Not known |
| Bone age method | TW20/ Radius-ulna-short bone/ Greulich & Pyle | Psychosocial Support Offered to Child | Yes/ No/ Not known |
| Bone mineral density | Yes/ No/ Not known | Ongoing Psychosocial Support for Child | Yes/ No/ Not known |
| Bone Mineral Density Date | dd/mm/yyyy | Age-appropriate Information to Child | Yes/ No/ Not known |
| Bone Mineral Density Result | Osteopenia/ Osteoporosis/ Normal | Has Child Questioned Their Gender | Yes/ No/ Not known |
| Puberty | Is Child Distressed About Gender Identity or Assignment | Yes/ No/ Not known | |
| Breast stage | 1/ 2/ 3/ 4/ 5/ Not Known | Physical or Mental Health Status Interferes with Daily Life Activities (education, work) | Yes / Partially / No |
| Genital stage | 1/ 2/ 3/ 4/ 5/ Not Known | Physical or Mental Health Status Interferes with Social Activities (hobbies, friends, relations) | Yes / Partially / No |
| Axillary hair stage | 1/ 2/ 3/ 4/ 5/ Not Known | Medication | |
| Pubic hair stage | 1/ 2/ 3/ 4/ 5/ Not Known | Testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Left testicular volume | ml | Oestrogen | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Right testicular volume | ml | DHT | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Stretched penile length | cm | Aromatase Inhibitor | Yes/ No/ Not known |
| Spontaneous puberty | Yes/ No/ Not known | GnRH analogues | Yes/ No/ Not known |
| Pubertal induction | Yes/ No/ Not known | Glucocorticoids | Yes/ No/ Not known |
| Induction with oestrogen | Yes (Oral, Transdermal)/ No/ Not known | Fludrocortisone | Yes/ No/ Not known |
| Induction with testosterone | Yes (Oral, Transdermal)/ No/ Not known | Other drugs | Yes/ No/ Not known |
| Menarche | Spontaneous/ Induced/ Not known | Lab Tests | |
| Hirsutism | Yes/ No/ Not known | LH | Low/ Normal/ High/ Not known |
| Gynaecomastia | Yes/ No/ Not known | FSH | Low/ Normal/ High/ Not known |
| Internal Phenotype | AMH | Low/ Normal/ High/ Not known | |
| Imaging Modality- Left testis | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Inhibin B | Low/ Normal/ High/ Not known |
| Imaging Modality- Right testis | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Androstenedione | Low/ Normal/ High/ Not known |
| Left testis Morphology | Absent/ Normal/ Small/ Abnormal | Total Testosterone | Low/ Normal/ High/ Not known |
| Right testis Morphology | Absent/ Normal/ Small/ Abnormal | Free Testosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Uterus | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Dihydrotestosterone | Low/ Normal/ High/ Not known |
| Uterus Morphology | Absent/ Normal/ Hypoplastic/ Abnormal | Oestradiol | Low/ Normal/ High/ Not known |
| Imaging Modality- Left ovary | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | 17-OHP | Low/ Normal/ High/ Not known |
| Imaging Modality- Right ovary | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Urine steroids | Normal/ Abnormal |
| Left ovary Morphology | Absent/ Streak/ Normal/ Polycystic | hCG Stimulation Test | Specify protocol |
| Right ovary Morphology | Absent/ Streak/ Normal/ Polycystic | Adrenal Stimulation Test | Specify protocol |
| Sexual Health | 11-deoxycortisol | Low/ Normal/ High/ Not known | |
| Menses | Yes/ Primary amenorrhoea/ Secondary amenorrhoea | Pregnenolone | Low/ Normal/ High/ Not known |
| Age at Menopause | 17-OH Pregnenolone | Low/ Normal/ High/ Not known | |
| Fertility Desired | Yes/ No/ Not known | DHEA | Low/ Normal/ High/ Not known |
| Tissue Storage | Yes/ No/ Not known | ||
| Sperm Assessment | Yes/ No/ Not known | ||
| Sperm count, per million/ml | x million per ml/ Normal/ Abnormal/ Not Reported | ||
| Number of Offspring | |||
| Assisted Conception | Yes/ No/ Not known | ||
*Associated conditions: CNS, Heart, Renal, Skeletal, Skin, ENT, Eyes, Blood and Lymp, Craniofacial, Adrenal, GI Tract, Haematological, Respiratory, SGA (Small for Gestational Age), Short stature, Non-defined syndrome, Other. ** Genital reconstructive surgery field may be repeated.
Much less evidence is available to guide timing of clinical revision in adulthood (Table 5). In favour of standardised assessment of young individuals aged 18–25 years is that they are in the process of gaining independence and have recently transitioned to adult care. Many young people are newly forming intimate relationships, which potentiates new concerns and/or required healthcare intervention. Topics such as sexual function, sexual orientation, and gender identity may become central in their lives. In addition, baseline information on typical health issues in adulthood such as bone mineral density, blood pressure, and obesity should be collected. Issues around fertility and forming a family may dominate between ages 25 and 40 years.
Adult assessment (once per interval: 18-25; 25-40; 40-60; 60-75 years)
| Parameters | Units/ options | Parameters | Units/ options |
|---|---|---|---|
| General | Surgery | ||
| Date of Assessment | dd/mm/yyyy | Left Gonad Biopsy | Yes/ No/ Not known |
| Age at Assessment | years | Right Gonad Biopsy | Yes/ No/ Not known |
| Weight | kg | Left Gonadectomy | Yes/ No/ Not known |
| Height | cm | Right Gonadectomy | Yes/ No/ Not known |
| BMI | kg/m2 | Genital reconstructive surgery** | None/ clitoral surgery / vaginal surgery / labioscrotal surgery / hypospadias surgery / urethral surgery other than hypospadias/ phalloplasty; age |
| Mothers Height | cm | Vaginal Hypoplasia | Yes / No/ Not known |
| Fathers Height | cm | Medical management of vaginal hypoplasia | Dilation / Surgery / None |
| Mid parental height | cm | Type of Vaginoplasty | Intestinal / Peritoneal / Davydov / Vecchietti / Baloon / Other |
| Original Sex Assigned | Male/ Female/ Both/ Not assigned/ Other | Post Surgical Complications of genital surgery | Yes/ No/ Not known; if yes, describe. |
| Current Gender | Male/ Female/ Both/ Not assigned/ Other | Gonadal Germ Cell Cancer | Yes/ No/ Not known |
| Adult raised as | Male/ Female/ Both / Other | Left Gonad | None/ GCNIS/ Gonadoblastoma/ Seminoma/ Non-seminoma/ Dysgerminoma/ Other |
| Associated Conditions* | Right Gonad | None/ GCNIS/ Gonadoblastoma/ Seminoma/ Non-seminoma/ Dysgerminoma/ Other | |
| Known Syndrome | Yes/ No | Breast surgery | None / breast reconstruction/augmentation/ reduction/ mastectomy |
| Bone age, bone mineral density | Post Surgical Complications of Breast Surgery | Yes/ No/ Not known; if yes, describe | |
| Bone age date | dd/mm/yyyy | Psychosocial, Gender Identity | |
| Bone age result | years | Change in Legal Sex | Yes/ No/ Not known |
| Bone age method | TW20/ Radius-ulna-short bone/ Greulich & Pyle | Psychosocial Support | Yes/ No/ Not known |
| Bone mineral density | Yes/ No/ Not known | Ongoing Psychosocial Support | Yes/ No/ Not known |
| Bone Mineral Density Date | dd/mm/yyyy | Full information about condition | Yes/ No/ Not known |
| Bone Mineral Density Result | Osteopenia/ Osteoporosis/ Normal | Gender role | Female/ Male/ Both/ Neither/ Not known |
| Puberty | Physical or Mental Health Status Interferes with Daily Life Activities (education, work) | Yes / Partially / No | |
| Breast stage | 1/ 2/ 3/ 4/ 5/ Not Known | Physical or Mental Health Status Interferes with Social Activities (hobbies, friends, relations) | Yes / Partially / No |
| Genital stage | 1/ 2/ 3/ 4/ 5/ Not Known | Sexual Health | |
| Axillary hair stage | Yes/No/ Not Known | Menses | Yes/ Primary amenorrhoea/ Secondary amenorrhoea |
| Pubic hair stage | 1/ 2/ 3/ 4/ 5/ 6/Not Known | Age at Menopause | years |
| Left testicular volume | ml | Fertility Desired | Yes/ No/ Not known |
| Right testicular volume | ml | Tissue Storage | Yes/ No/ Not known |
| Spontaneous puberty | Yes/ No/ Not known | Sperm Assessment | Yes/ No/ Not known |
| Pubertal induction | Yes/ No/ Not known | Sperm count, per million/ml | x million per ml/ Normal/ Abnormal/ Not Reported |
| Induction with oestrogen | Yes (Oral, Transdermal)/ No/ Not known | Number of Offspring | |
| Induction with testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known | Assisted Conception | Yes/ No/ Not known |
| Menarche | Spontaneous/ Induced/ Not known | Medication | |
| Hirsutism | Yes/ No/ Not known | Testosterone | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Gynaecomastia | Yes/ No/ Not known | Oestrogen (E) | Yes (IM, Oral, Transdermal)/ No/ Not known |
| Co-morbidities | DHT | Yes (IM, Oral, Transdermal)/ No/ Not known | |
| Osteoporosis | Yes/ No/ Not known | Aromatase Inhibitor | Yes/ No/ Not known |
| Type II Diabetes | Yes/ No/ Not known | GnRH analogues | Yes/ No/ Not known |
| Chronic Kidney Disease | Yes/ No/ Not known | Glucocorticoids | Yes/ No/ Not known |
| Chronic Liver Disease | Yes/ No/ Not known | Fludrocortisone | Yes/ No/ Not known |
| Central Nervous System | Yes/ No/ Not known | Progestin (P) | Yes (Oral, Subcutaneous, IM, IUD) / No/ Unknown |
| Hypertension | Yes/ No/ Not known | Combined E/P (HRT/OC***) | Yes (Oral, Transdermal, Vaginal)/ No/ Not known |
| Other | Yes/ No/ Not known; if yes, describe | Other drugs | Yes/ No/ Not known |
| Internal Phenotype | Lab Tests | ||
| Imaging Modality- Left testis | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | LH | Low/ Normal/ High/ Not known |
| Imaging Modality- Right testis | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | FSH | Low/ Normal/ High/ Not known |
| Left testis Morphology | Absent/ Normal/ Small/ Abnormal | AMH | Low/ Normal/ High/ Not known |
| Right testis Morphology | Absent/ Normal/ Small/ Abnormal | Inhibin B | Low/ Normal/ High/ Not known |
| Imaging Modality- Uterus | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Androstenedione | Low/ Normal/ High/ Not known |
| Uterus Morphology | Absent/ Normal/ Hypoplastic/ Abnormal | Total Testosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Left ovary | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Free Testosterone | Low/ Normal/ High/ Not known |
| Imaging Modality- Right ovary | US/ MRI/ Genitogram/ Laparoscopy/ Genitoscopy | Dihydrotestosterone | Low/ Normal/ High/ Not known |
| Left ovary Morphology | Absent/ Streak/ Normal/ Polycystic | Oestradiol | Low/ Normal/ High/ Not known |
| Right ovary Morphology | Absent/ Streak/ Normal/ Polycystic | 17-OHP | Low/ Normal/ High/ Not known |
| Urine steroids | Normal/ Abnormal | ||
| hCG Stimulation Test | Specify protocol | ||
| Adrenal Stimulation Test | Specify protocol | ||
| 11-deoxycortisol | Low/ Normal/ High/ Not known | ||
| Pregnenolone | Low/ Normal/ High/ Not known | ||
| 17-OH Pregnenolone | Low/ Normal/ High/ Not known | ||
| DHEA | Low/ Normal/ High/ Not known | ||
*Associated conditions: CNS, Heart, Renal, Skeletal, Skin, ENT, Eyes, Blood and Lymp, Craniofacial, Adrenal, GI Tract, Haematological, Respiratory, SGA (Small for Gestational Age), Short stature, Non-defined syndrome, Other; ** Genital reconstructive surgery field may be repeated; ***Hormonal replacement treatment/Oral contraceptives
During the age intervals of 40–60 and 60–80 years, long-term effects of treatment or (lack of) hormonal treatment and comorbidities may become apparent (8). Physical and mental health issues of adults living with a DSD are major determinants of overall quality of life (QoL) (4). It is therefore crucial to capture such information in order to allow for future research and appropriate management.
Genetic and biochemical data
Most causes of DSD are genetic; however, drugs, environmental toxins, and maternal and placental causes are also relevant and/or may influence outcomes. A clear diagnosis can determine the spectrum of potentially affected organs, current/future health consequences, and treatment options (8).
A comprehensive diagnostic approach consists of an extensive family history over at least three generations, as well as a physical exam of the whole body which includes the genital organs. This will then guide the clinician towards further diagnostic imaging, biochemical and genetic studies. Guidelines for the clinical, biochemical, and genetic work-up of DSD have been published elsewhere (12, 15, 16).
Collecting genetic information, together with clinical and biochemical data, in a centralised registry allows identification and characterisation of DSD subgroups, including those for which a genetic diagnosis has not been achieved so far. It is possible then to test the diagnostic reliability of specific biochemical and genetic parameters and their usefulness for implementation in clinical diagnostic guidelines. It will also enable studies on the impact of a molecular genetic diagnosis on outcome. Indeed, almost 50% of individuals who have a 46,XY DSD have no genetic diagnosis, and it remains debatable whether and how this impacts management and overall QoL (17).
Although DSDs are congenital conditions, the function of affected organs may decline over time, e.g. testicular function in 45,X/46,XY boys (18). Therefore, any initially performed diagnostic laboratory investigation may need to be repeated, if in doubt and of therapeutic consequence. Hormonal and other drug treatments need to be controlled with regular intervals for correct dosing, effectiveness and side effects. Biochemical parameters that qualify best for treatment monitoring need to be identified based on prospectively collected data.
In some individuals who have an unknown cause of their condition, genetic work-up has been performed years ago with methods that are currently outdated. In others, whole exome or whole genome sequencing may reveal variants of unknown significance or monogenetic variants in established DSD genes that do not clearly explain the observed phenotype (e.g. heterozygous MAMLD1 mutations) (19). Finally, DSD genetics may be more complex than initially thought, as demonstrated recently (20). Therefore, genetic results may also require re-evaluation as new knowledge is gained over time.
Medical fields
Family data
A detailed family history, including fertility, is essential to explore possible inheritance mechanisms and to lend support for molecular genetic investigations in individuals with milder phenotypes. Phenotypic variability within families may be broad and may comprise subfertility/infertility as the only sign, depending on the severity of the mutation (21, 22).
Associated conditions
Several comorbidities and non-gonadal organ dysfunctions are associated with specific DSDs (23). Further exploration of these associations is important for targeted follow-up of affected individuals and for understanding the mechanisms of disease. As many DSD conditions are caused by mutations in transcription factors that regulate the development of several organ systems, this may result in combined functional defects, as for example in WT1 (kidney involvement), NR5A1 (adrenal involvement, spleen hypoplasia) or GATA4 (cardiac defects) mutations (24, 25, 26, 27). Associated conditions are mostly found in chromosomal DSD such as 45,X/46,XY and may only develop over time, requiring medical attention at each follow-up visit, for example cardiac surveillance in all individuals who have 45,X/46,XY mosaicism (18, 28).
External and internal genital phenotype
As genital photography and storage faces ethical and legal challenges, standardised tools are needed to objectively describe the genital aspect in detail. Qualitative visual scales such as the Prader (29) or Quigley (30) scales are highly observer dependent and do not consider internal and external genital status separately. The anogenital distance correlates with prenatal androgen exposure but lacks standardisation and is difficult to perform in children above 1 year (31). The External Masculinization Score (EMS) is a practical and objective tool, has good inter-observer reliability and correlates with relevant clinical outcomes (12, 32, 33). Limitations include its restricted applicability – only male neonates – and dichotomous nature (e.g. micropenis yes/no). To overcome these problems, a modified EMS, termed “external genitalia score” (EGS), has been developed. The EGS assesses the same anatomical landmarks as EMS while using a gender-neutral vocabulary applicable in all infants up to 2 years of age, and a more gradual scale, reflecting the naturally occurring phenotypic variability of external genitalia. Reference ranges for a mixed European population have been determined (S van der Straaten, A Springer, A Zecic, D Hebenstreit, U Tonnhofer, A Gawlik, M Baumert, K Szeliga, S Debulpaep, A Desloovere et al. The external genitalia score (EGS): A European multicenter validation study 2019; personal communication). Additional parameters such as penile curvature and tissue quality are likely related to (surgical) outcome, but these are currently ill-defined and require further study. Reliable assessment of internal genitalia requires imaging and sometimes surgical procedures such as laparoscopy. Knowledge on the internal anatomy can be helpful in cases where the initial sex/gender of rearing is unclear and to foresee possible complications. Imaging techniques have significant differences in sensitivity, sensibility, and invasiveness. In the longer term, meta-analysis of data will provide further insights on the procedure of choice in specific situations.
The genital phenotype and other sex characteristics change as the individual grows or as a result of hormonal treatment or surgery. Frequent genital inspection is not recommended, but may be helpful in specific situations, especially as it can help parents and children / adolescents to understand that there is a natural variation in clitoral sizes and genital aspect or to discuss eventual parental or patient worries. For example, in 46,XX individuals who have CAH, clitoral size may decrease in response to glucocorticoid treatment after the newborn period. This finding is often very reassuring for parents and may actually convince them that the genital aspect has indeed become unremarkable for a lay person taking care of their baby. On the other hand, clitoral size may increase in periods of undertreatment or non-compliance (34, 35) and/or adolescent girls may feel insecure about its aspect. Thoughtful genital inspection in an adolescent girl, after having obtained her consent, may sometimes help her discussing eventual worries about the genital aspect and/or reassure her that clitoral sensitivity is most important and that the clitoral aspect falls within the natural variation. Gonadal failure may result in the lack or arrest of pubertal development. In such cases, it is important to document genital pubertal progression at the suggested time intervals. Suspicion of complications, e.g. fistulae after hypospadias surgery will also require a genital exam.
In adult life, psychosexual function is an even more important outcome parameter and should be discussed as suggested in Table 5; sometimes, depending on the specific question (eg worries about penile length), this will need to be done in parallel with a genital examination (1 S van der Straaten, A Springer, A Zecic, D Hebenstreit, U Tonnhofer, A Gawlik, M Baumert, K Szeliga, S Debulpaep, A Desloovere et al. The external genitalia score (EGS): A European multicenter validation study 2019; personal communication).
Anthropometric data, body composition and bone health
Documentation of birth weight and length, growth, body composition and bone health parameters is crucial as it may reveal the long-term outcomes of childhood processes such as the postnatal hypothalamic-pituitary-gonadal activation (the ‘mini-puberty’) and growth patterns in DSD other than Turner syndrome (TS) and Klinefelter syndrome (KS), where evidence is currently scarce. For example, no data are available on the prevalence and extent of catch-up growth in children with atypical genitalia who were born small for gestational age. In individuals with 45X/46XY karyotypes, growth hormone treatment has variable effects and may need to be optimised (36, 37). Age at start of puberty induction and dosing of sex steroids may affect the growth pattern and body proportions (38). Glucocorticoid overtreatment compromises growth and leads to increased weight and BMI in the longer term (39). Both androgens and oestrogens are important for bone mass accrual and maintenance. Overtreatment with glucocorticoids, vitamin D deficiency, physical activity, and hereditary factors may influence bone health (40).
Medical treatments
Some treatments are offered early in life, but evidence of their long-term efficacy may be lacking, for example, testosterone or dihydrotestosterone (DHT) for micropenis (41). The use of some medications is experimental (e.g. aromatase inhibitors to block the effect of sex hormones (42, 43) or metformin to avoid metabolic consequences (44)), but others, such as growth hormone, gluco- and mineralocorticoids, l-thyroxin, insulin and sex hormone replacement therapy are frequently used in DSD and need constant surveillance and adjustments (45, 46, 47). Standardised guidelines are lacking for most DSD conditions, with the exception of TS and KS (45, 48).
Lifelong steroid and sex hormone replacement therapy may induce side effects that negatively (or positively) impact QoL (4) and optimal dosing may vary with age (49, 50). Very few studies address medical needs to optimise sexual function and to avoid secondary health consequences, especially at older ages. In addition, treatment regimens differ widely across centres and comparison of these protocols may further improve patient management and health-related QoL in the future (2, 51). Large-scale registration and in-depth analysis of comorbidities and of chronic use of certain medications aim to improve care and to positively alter outcomes.
Particular attention has been given to the prenatal treatment of a foetus possibly affected by 21-hydroxylase deficiency with dexamethasone administered to the mother. Benefit-risk ratio is still unclear, and it is currently regarded as experimental (35). From another perspective, drugs such as pain killers given to pregnant women and (environmental) toxins may affect foetal sexual development and fertility (52). This important domain is largely unexplored, and collecting detailed information related to this topic is essential for future exploration.
Fertility and documentation of gonadal cancers
Fertility is strongly reduced in all forms of DSD, for biological and/or psychosocial reasons. Contemporary assisted reproductive techniques (ART) can increase chances to have biological children for some azoospermic individuals with 46,XY DSD and for some who have viable eggs (53, 54). Uterus transplantations have resulted in live births (55). It is anticipated that improvement of hormonal therapies and new technologies (e.g. in vitro generation of induced primordial germ cell-like cells) (56) may further increase fertility rates in the future. Assessment and documentation of reproductive capacity of the gonads independent of the patients’ social gender has the aim of understanding condition-specific fertility chances (57). It can also facilitate access to international research protocols in this field through recruitment of registered patients.
The mechanisms underlying germ cell cancer development in DSD are increasingly understood. Routine prophylactic gonadectomy to prevent germ cell cancer development is no longer recommended in all individuals at risk; guidelines for selective gonadectomy and surveillance of retained gonads have been published (58, 59). Given the recent practice changes, no long-term outcome data on tumour risk in adulthood are available today, and with the possible exception of complete androgen insensitivity (59, 60), individualised management is hampered by a paucity of condition-specific data (58, 61). Therefore, current recommendations may need to be adjusted based on future insights. With a molecular genetic diagnosis more often reached today, and with systematic registration of pathology results and centralised review of challenging cases, further progress in this matter can be achieved (62).
Surgical fields
Childhood surgery
There are few evidence-based indications for gonadal or genital surgery in early childhood. Gonadal biopsy may, in exceptional cases, support important decisions, for example in relation to sex of rearing in the context of suspected (ovo)testicular DSD (63). Following international criticism of early genital surgery, many centres have restricted such procedures (9). Although debated, early surgery is still offered by some centres for 46,XX CAH patients with severe genital virilisation and for 46,XY patients with hypospadias. Other centres have restricted such procedures and consider alternative options such as raising severely virilised 46,XX CAH children as males and offer extensive parental support to enhance the information and decision-making process. The developmental, familial, and societal impact of growing up with atypical-looking genitalia is currently not well understood. Psychosocial support appears crucial, and detailed documentation of such decisions in a multicentre registry is essential to allow urgent studies on their appropriateness and long-term consequences (64). Systematic registration can also demonstrate the time and pace needed to definitively implement the proposed practice changes.
There is no scientific evidence nor expert consensus on how surgery or refraining from surgery impacts the individual, family, society, or risk of stigmatisation (1). Standardised and detailed documentation of performed procedures, complications and reasons for and outcome of (non-) intervention are therefore crucial (9). As the focus of many performed genital surgeries nowadays is more on function than in relation to gender assignment, a specific description should be used for the intervention or the reasons to intervene rather than referring to ‘feminising / masculinising’ genital surgery.
Genital examinations
Genital examinations should be limited and should have a clear and transparent purpose. Living with atypical-looking genitals and/or having had genital surgery may pose psychological and psychosexual challenges that require timely referral to a psychologist or sexologist. This person can then further perform a psychological evaluation, using standardised diagnostic measures and propose appropriate support if needed. The applied methodology depends on the specific goal of such an assessment. No DSD-specific questionnaires to assess psychological and/or psychosexual functioning currently exist, and interpretation of results is seriously hampered by methodological limitations, highlighting the need for psychologists with good knowledge of and experience with the various conditions and for further professional training in this field (65).
Follow-up of adults
Follow-up of adults who had genital surgery in infancy is rarely organised in the routine clinical setting. High-quality outcome and longitudinal studies are scarce. Difficulties include differences in technical terms, modifications of surgical techniques over the years, heterogeneity of DSD conditions and reporting bias of surgeons towards the techniques they are most experienced with (66). Comprehensive assessment ideally includes recording complications and redo surgery (also in adulthood), cosmetic appearance, functional outcome (micturition, sexuality), and quality of psychosexual life as a minimum, all in relation to preoperative findings and assessed both by a professional and by self-assessment (67, 68, 69, 70).
The hypospadias objective penile evaluation score (HOPE) has been designed for standardised cosmetic evaluation by a professional of hypospadias surgery (71). Although practical and objective, HOPE has important shortcomings, such as the use of genital pictures, lack of evaluation of the scrotum and of possibilities for self-assessment, most notably of penile size, which is considered crucial by many patients (72). A subjective cosmetic evaluation of hypospadias surgery can be obtained with the penile perception score (PPS) and its paediatric variant (PPPS) (73, 74). All the above lack functional parameters such as micturition pattern and erection and ejaculation capacity. A suggestion for a non-photography-based modified HOPE score, with addition of relevant functional and self-perceived assessments is provided in Supplementary Table 1 (see section on supplementary data given at the end of this article).
Different measures have been used for gynaecological and sexual function assessments of the female genitalia (e.g. (66, 70, 75)). Standardised tools for assessing long-term functional and cosmetic outcome of female genital surgery are in development. Items that are important to assess are listed in Supplementary Table 2.
Psychosocial fields
Trends in sex assignment have changed over the years (33). Sex and gender are fundamental in the development of a person’s identity, as well as the individual’s integrity, self-esteem, and social relations. Inappropriate focus or a normative perspective on genital, sexual, and psychological issues may cause annoyance or stigmatisation. Therefore, questions about a person’s gender experience and gender well-being should be posed with respect for the individual’s integrity and in an open-ended way that does not presume a particular gender or increase shame and stigma (65). Both children and adolescents should be given the possibility to talk about these issues without a parent being present (13).
Assessment of an individual’s mental well-being and need for psychosocial support should be part of standard care throughout life. Physical or mental health problems are highly prevalent in individuals who have a DSD (2, 8). Importantly, not the specific diagnosis but the personal health status predicts QoL (4). Overall, individuals with a DSD report good QoL but studies are often contradictory, possibly due to differences in local treatment and care, age and cultural context and differences in methodology. Appropriate QoL questionnaires should focus on social and psychological domains that are relevant for individuals who have a DSD (76). In addition, patient-reported outcome measures related to QoL at all life stages are considered most crucial by patients, and it is clear that they have a central place in holistic care (77). Formal QoL assessment in the context of routine clinical practice is unusual, but as a minimum, it is suggested to record the impact of the condition on the patients’ daily life by including a relevant proxy for this. While awaiting more specific key questions, preferably developed by support groups and other stakeholders, a generic set of simple questions is proposed here, which can be adjusted to all ages.
Considering all conditions together, the prevalence of gender dysphoria is only slightly increased in DSD. However, assessing gender identity and gender-related behaviour according to a strict binary or pathologising model will insufficiently capture the broad spectrum of gender-related outcomes (78). Currently, hardly any instrument is available that allows gender assessment according to a spectral rather than a bimodal paradigm. Therefore, new measures and instruments, using a non-binary vocabulary and taking all possible gender outcomes into account need to be developed. In addition, gender role behaviour rather than gender well-being has been given (too) much attention in the past. Indeed, it is crucial not to misinterpret behaviour or sexual orientation as signs of gender dysphoria (11).
From the beginning, psychosocial support for parents, aiming at an enhanced understanding of the medical context and the diagnostic investigations are crucial factors for coping with psychological distress (79). Parent-child bonding, coping abilities and symptoms of stress are important indicators of parental needs on this matter (12). In the presence of a genital difference, parents need guidance on how to raise resilient children and how to communicate early with their child about the condition, including consequences for gender development and past and future treatment options (80). To what extent psychosocial support and early information may contribute to optimisation of outcomes has never been documented in the context of DSD. Providing further evidence in favour of such support may convince policy makers to invest in psychological counselling, as an important part of preventive care and as a valuable alternative to genital surgery, amongst others (81, 82).
Many registries such as I-DSD are developing sections that include possibilities for self-reporting of relevant outcome measures, such as reasons for genital surgery or not having such surgery, and self-reported QoL. Altogether, considering the voices of people with DSD and their parents, research and care of DSD can move from a researcher-driven to a participant-driven approach.
Conclusions and perspectives
Consensus was reached on standardised assessments of individuals who have a DSD and on the ages at which clinical revision should be performed in order to capture crucial developmental milestones and/or long-term consequences of the various conditions. In the clinical setting, the tool will ensure and support a high quality of clinical care. Long-term and wide use of this instrument, for example, through the I-DSD Registry, will allow answering critical research questions in the future specifically in relation to outcome, treatment options, comorbidities in adult age and fertility. In addition, patient-reported outcome measures, obtained through patient portals, are expected to become increasingly important and may also be implemented in the I-DSD Registry in the near future.
Supplementary data
This is linked to the online version of the paper at https://doi.org/10.1530/EJE-19-0363.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding
This article is based upon work from COST Action DSDnet, supported by COST (European Cooperation in Science and Technology) as BM1303. MC holds a senior clinical investigator grant from the Research Foundation Flanders. CEF is supported by the Swiss National Science Foundation (grant number 320030-146127). AN holds a senior clinical research position funded by Karolinska and Stockholm County Council. BK is supported by a grant from the European Union Seventh Framework Programme (FP7/2007-2013) grant n° 305373.
References
- 1↑
Lee PA, Nordenstrom A, Houk CP, Ahmed SF, Auchus R, Baratz A, Baratz Dalke K, Liao LM, Lin-Su K & Looijenga LH, et al.Global disorders of sex development update since 2006: perceptions, approach and care. Hormone Research in Paediatrics 2016 158–180. (https://doi.org/10.1159/000442975)
- 2↑
Falhammar H, Claahsen-van der Grinten H, Reisch N, Slowikowska-Hilczer J, Nordenström A, Roehle R, Bouvattier C, Kreukels BPC, Köhler B & dsd-LIFE Group. Health status in 1040 adults with disorders of sex development (DSD): a European multicenter study. Endocrine Connections 2018 466–478. (https://doi.org/10.1530/EC-18-0031)
- 3↑
van de Grift TC, Cohen-Kettenis PT, de Vries ALC & Kreukels BPC on behalf of dsd-LIFE. Body image and self-esteem in disorders of sex development: a European multicenter study. Health Psychology 2018 334–343. (https://doi.org/10.1037/hea0000600)
- 4↑
Rapp M, Mueller-Godeffroy E, Lee P, Roehle R, Kreukels BPC, Köhler B, Nordenström A, Bouvattier C, Thyen U & dsd-LIFE group. Multicentre cross-sectional clinical evaluation study about quality of life in adults with disorders/differences of sex development (DSD) compared to country specific reference populations (dsd-LIFE). Health and Quality of Life Outcomes 2018 54 . (https://doi.org/10.1186/s12955-018-0881-3)
- 5↑
Thyen U, Ittermann T, Flessa S, Muehlan H, Birnbaum W, Rapp M, Marshall L, Szarras-Capnik M, Bouvattier C & Kreukels BPC, et al.Quality of health care in adolescents and adults with disorders/differences of sex development (DSD) in six European countries (dsd-LIFE). BMC Health Services Research 2018 527 . (https://doi.org/10.1186/s12913-018-3342-0)
- 6↑
Hiort O, Birnbaum W, Marshall L, Wunsch L, Werner R, Schroder T, Dohnert U, Holterhus PM. Management of disorders of sex development. Nature Reviews. Endocrinology 2014 520–529. (https://doi.org/10.1038/nrendo.2014.108)
- 7↑
Thyen U, Lux A, Jurgensen M, Hiort O, Kohler B. Utilization of health care services and satisfaction with care in adults affected by disorders of sex development (DSD). Journal of General Internal Medicine 2014 (Supplement 3) S752–S759. (https://doi.org/10.1007/s11606-014-2917-7)
- 8↑
Cools M, Nordenstrom A, Robeva R, Hall J, Westerveld P, Fluck C, Kohler B, Berra M, Springer A & Schweizer K, et al.Caring for individuals with a difference of sex development (DSD): a consensus statement. Nature Reviews. Endocrinology 2018 415–429. (https://doi.org/10.1038/s41574-018-0010-8)
- 9↑
Gorduza DB, Quigley CA, Caldamone AA, Mouriquand PDE. Surgery of anomalies of gonadal and genital development in the "post-truth era". Urologic Clinics of North America 2018 659–669. (https://doi.org/10.1016/j.ucl.2018.06.012)
- 10↑
Baratz AB, Sharp MK, Sandberg DE. Disorders of sex development peer support. Endocrine Development 2014 99–112. (https://doi.org/10.1159/000363634)
- 11↑
Kreukels BPC, Köhler B, Nordenström A, Roehle R, Thyen U, Bouvattier C, de Vries ALC, Cohen-Kettenis PT & dsd-LIFE group. Gender dysphoria and gender change in disorders of sex development/intersex conditions: results from the dsd-LIFE study. Journal of Sexual Medicine 2018 777–785. (https://doi.org/10.1016/j.jsxm.2018.02.021)
- 12↑
Ahmed SF, Achermann JC, Arlt W, Balen A, Conway G, Edwards Z, Elford S, Hughes IA, Izatt L & Krone N, et al.Society for Endocrinology UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development (revised 2015). Clinical Endocrinology 2016 771–788. (https://doi.org/10.1111/cen.12857)
- 13↑
Nordenstrom A, Thyen U. Improving the communication of healthcare professionals with affected children and adolescents. Endocrine Development 2014 113–127. (https://doi.org/10.1159/000363636)
- 14↑
Crouch NS, Creighton SM. Transition of care for adolescents with disorders of sex development. Nature Reviews. Endocrinology 2014 436–442. (https://doi.org/10.1038/nrendo.2014.62)
- 15↑
Kulle A, Krone N, Holterhus PM, Schuler G, Greaves RF, Juul A, de Rijke YB, Hartmann MF, Saba A & Hiort O, et al.Steroid hormone analysis in diagnosis and treatment of DSD: position paper of EU COST Action BM 1303 'DSDnet'. European Journal of Endocrinology 2017 176 P1–P9. (https://doi.org/10.1530/EJE-16-0953)
- 16↑
Audi L, Ahmed SF, Krone N, Cools M, McElreavey K, Holterhus PM, Greenfield A, Bashamboo A, Hiort O & Wudy SA, et al.GENETICS IN ENDOCRINOLOGY: approaches to molecular genetic diagnosis in the management of differences/disorders of sex development (DSD): position paper of EU COST Action BM 1303 'DSDnet'. European Journal of Endocrinology 2018 R197–R206. (https://doi.org/10.1530/EJE-18-0256)
- 17↑
Alhomaidah D, McGowan R, Ahmed SF. The current state of diagnostic genetics for conditions affecting sex development. Clinical Genetics 2017 157–162. (https://doi.org/10.1111/cge.12912)
- 18↑
Lindhardt Johansen M, Hagen CP, Rajpert-De Meyts E, Kjaergaard S, Petersen BL, Skakkebaek NE, Main KM, Juul A. 45,X/46,XY mosaicism: phenotypic characteristics, growth, and reproductive function--a retrospective longitudinal study. The Journal of Clinical Endocrinology and Metabolism 2012 E1540–E1549. (https://doi.org/10.1210/jc.2012-1388)
- 19↑
Camats N, Fernandez-Cancio M, Audi L, Mullis PE, Moreno F, Gonzalez Casado I, Lopez-Siguero JP, Corripio R, Bermudez de la Vega JA & Blanco JA, et al.Human MAMLD1 gene variations seem not sufficient to explain a 46,XY DSD phenotype. PLOS ONE 2015 e0142831 . (https://doi.org/10.1371/journal.pone.0142831)
- 20↑
Camats N, Fernandez-Cancio M, Audi L, Schaller A, Fluck CE. Broad phenotypes in heterozygous NR5A1 46,XY patients with a disorder of sex development: an oligogenic origin? European Journal of Human Genetics 2018 1329–1338. (https://doi.org/10.1038/s41431-018-0202-7)
- 21↑
Ollivier M, Paris F, Philibert P, Garnier S, Coffy A, Fauconnet-Servant N, Haddad M, Guys JM, Reynaud R & Faure A, et al.Family history is underestimated in children with isolated hypospadias: a French multicenter report of 88 families. Journal of Urology 2018 890–894. (https://doi.org/10.1016/j.juro.2018.04.072)
- 22↑
Portnoi MF, Dumargne MC, Rojo S, Witchel SF, Duncan AJ, Eozenou C, Bignon-Topalovic J, Yatsenko SA, Rajkovic A & Reyes-Mugica M, et al.Mutations involving the SRY-related gene SOX8 are associated with a spectrum of human reproductive anomalies. Human Molecular Genetics 2018 1228–1240. (https://doi.org/10.1093/hmg/ddy037)
- 23↑
Cox K, Bryce J, Jiang J, Rodie M, Sinnott R, Alkhawari M, Arlt W, Audi L, Balsamo A & Bertelloni S, et al.Novel associations in disorders of sex development: findings from the I-DSD Registry. The Journal of Clinical Endocrinology and Metabolism 2014 E348–E355. (https://doi.org/10.1210/jc.2013-2918)
- 24↑
Lourenco D, Brauner R, Rybczynska M, Nihoul-Fekete C, McElreavey K, Bashamboo A. Loss-of-function mutation in GATA4 causes anomalies of human testicular development. Proceedings of the National Academy of Sciences of the United States of America 2011 1597–1602. (https://doi.org/10.1073/pnas.1010257108)
- 25↑
Lipska BS, Ranchin B, Iatropoulos P, Gellermann J, Melk A, Ozaltin F, Caridi G, Seeman T, Tory K & Jankauskiene A, et al.Genotype-phenotype associations in WT1 glomerulopathy. Kidney International 2014 1169–1178. (https://doi.org/10.1038/ki.2013.519)
- 26↑
Achermann JC, Ozisik G, Ito M, Orun UA, Harmanci K, Gurakan B, Jameson JL. Gonadal determination and adrenal development are regulated by the orphan nuclear receptor steroidogenic factor-1, in a dose-dependent manner. The Journal of Clinical Endocrinology and Metabolism 2002 1829–1833. (https://doi.org/10.1210/jcem.87.4.8376)
- 27↑
Colson C, Aubry E, Cartigny M, Remy AA, Franquet H, Leroy X, Kechid G, Lefevre C, Besson R & Cools M, et al.SF1 and spleen development: new heterozygous mutation, literature review and consequences for NR5A1-mutated patient's management. Clinical Genetics 2017 99–103. (https://doi.org/10.1111/cge.12957)
- 28↑
De Groote K, Cools M, De Schepper J, Craen M, Francois I, Devos D, Carbonez K, Eyskens B, De Wolf D. Cardiovascular pathology in males and females with 45,X/46,XY mosaicism. PLOS ONE 2013 e54977 . (https://doi.org/10.1371/journal.pone.0054977)
- 30↑
Quigley CA, De Bellis A, Marschke KB, el-Awady MK, Wilson EM, French FS. Androgen receptor defects: historical, clinical, and molecular perspectives. Endocrine Reviews 1995 271–321. (https://doi.org/10.1210/edrv-16-3-271)
- 31↑
Thankamony A, Pasterski V, Ong KK, Acerini CL, Hughes IA. Anogenital distance as a marker of androgen exposure in humans. Andrology 2016 616–625. (https://doi.org/10.1111/andr.12156)
- 32↑
Ahmed SF, Khwaja O, Hughes IA. The role of a clinical score in the assessment of ambiguous genitalia. BJU International 2000 120–124. (https://doi.org/10.1046/j.1464-410x.2000.00354.x)
- 33↑
Kolesinska Z, Ahmed SF, Niedziela M, Bryce J, Molinska-Glura M, Rodie M, Jiang J, Sinnott RO, Hughes IA & Darendeliler F, et al.Changes over time in sex assignment for disorders of sex development. Pediatrics 2014 e710–e715. (https://doi.org/10.1542/peds.2014-1088)
- 34↑
Bougneres P, Bouvattier C, Cartigny M, Michala L. Deferring surgical treatment of ambiguous genitalia into adolescence in girls with 21-hydroxylase deficiency: a feasibility study. International Journal of Pediatric Endocrinology 2017 3 . (https://doi.org/10.1186/s13633-016-0040-8)
- 35↑
Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH & Oberfield SE, et al.Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism 2018 4043–4088. (https://doi.org/10.1210/jc.2018-01865)
- 36↑
Bertelloni S, Baroncelli GI, Massart F, Toschi B. Growth in boys with 45,X/46,XY mosaicism: effect of growth hormone treatment on statural growth. Sexual Development : Genetics, Molecular Biology, Evolution, Endocrinology, Embryology, and Pathology of Sex Determination and Differentiation 2015 183–189. (https://doi.org/10.1159/000441342)
- 37
Martinerie L, Morel Y, Gay CL, Pienkowski C, de Kerdanet M, Cabrol S, Lecointre C, Coutant R, Baron S & Colle M, et al.Impaired puberty, fertility, and final stature in 45,X/46,XY mixed gonadal dysgenetic patients raised as boys. European Journal of Endocrinology 2012 687–694. (https://doi.org/10.1530/EJE-11-0756)
- 38↑
Onland-Moret NC, Peeters PH, van Gils CH, Clavel-Chapelon F, Key T, Tjonneland A, Trichopoulou A, Kaaks R, Manjer J & Panico S, et al.Age at menarche in relation to adult height: the EPIC study. American Journal of Epidemiology 2005 623–632. (https://doi.org/10.1093/aje/kwi260)
- 39↑
Hagenfeldt K, Martin Ritzen E, Ringertz H, Helleday J, Carlstrom K. Bone mass and body composition of adult women with congenital virilizing 21-hydroxylase deficiency after glucocorticoid treatment since infancy. European Journal of Endocrinology 2000 667–671. (https://doi.org/10.1530/eje.0.1430667)
- 40↑
Vanderschueren D, Laurent MR, Claessens F, Gielen E, Lagerquist MK, Vandenput L, Borjesson AE, Ohlsson C. Sex steroid actions in male bone. Endocrine Reviews 2014 906–960. (https://doi.org/10.1210/er.2014-1024)
- 41↑
Callens N, De Cuypere G, Van Hoecke E, T'Sjoen G, Monstrey S, Cools M, Hoebeke P. Sexual quality of life after hormonal and surgical treatment, including phalloplasty, in men with micropenis: a review. Journal of Sexual Medicine 2013 2890–2903. (https://doi.org/10.1111/jsm.12298)
- 42↑
Hawton K, Walton-Betancourth S, Rumsby G, Raine J, Dattani M. Growth hormone with aromatase inhibitor may improve height in CYP11B1 congenital adrenal hyperplasia. Pediatrics 2017 . (https://doi.org/10.1542/peds.2016-0730)
- 43
Merke DP, Cutler GB, Jr. New ideas for medical treatment of congenital adrenal hyperplasia. Endocrinology & Metabolism Clinics of North America 2001 121–135. (https://doi.org/10.1016/S0889-8529(08)70022-7)
- 44↑
Mapas-Dimaya AC, Agdere L, Bahtiyar G, Mejia JO, Sacerdote AS. Metformin-responsive classic salt-losing congenital adrenal hyperplasia due to 21-hydroxylase deficiency: a case report. Endocrine Practice 2008 889–891. (https://doi.org/10.4158/EP.14.7.889)
- 45↑
Gravholt CH, Andersen NH, Conway GS, Dekkers OM, Geffner ME, Klein KO, Lin AE, Mauras N, Quigley CA & Rubin K, et al.Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting. European Journal of Endocrinology 2017 G1–G70. (https://doi.org/10.1530/EJE-17-0430)
- 46↑
Bojesen A, Kristensen K, Birkebaek NH, Fedder J, Mosekilde L, Bennett P, Laurberg P, Frystyk J, Flyvbjerg A & Christiansen JS, et al.The metabolic syndrome is frequent in Klinefelter's syndrome and is associated with abdominal obesity and hypogonadism. Diabetes Care 2006 1591–1598. (https://doi.org/10.2337/dc06-0145)
- 47↑
Poyrazoglu S, Darendeliler F, Ahmed SF, Hughes I, Bryce J, Jiang J, Rodie M, Hiort O, Hannema SE & Bertelloni S, et al.Birth weight in different etiologies of disorders of sex development. The Journal of Clinical Endocrinology and Metabolism 2017 1044–1050. (https://doi.org/10.1210/jc.2016-3460)
- 48↑
Chang S, Skakkebaek A, Gravholt CH. Klinefelter syndrome and medical treatment: hypogonadism and beyond. Hormones (Athens) 2015 531–548. (https://doi.org/10.14310/horm.2002.1622)
- 49↑
Arlt W, Willis DS, Wild SH, Krone N, Doherty EJ, Hahner S, Han TS, Carroll PV, Conway GS & Rees DA, et al.Health status of adults with congenital adrenal hyperplasia: a cohort study of 203 patients. The Journal of Clinical Endocrinology and Metabolism 2010 5110–5121. (https://doi.org/10.1210/jc.2010-0917)
- 50↑
Nordenstrom A, Rohle R, Thyen U, Bouvattier C, Slowikowska-Hilczer J, Reisch N, Claahsen van der Grinten H, Brac de la Perriere A, Cohen-Kettenis PT & Kohler B, et al.Hormone therapy and patient satisfaction with treatment, in a large cohort of diverse disorders of sex development. Clinical Endocrinology 2018 397–408. (https://doi.org/10.1111/cen.13518)
- 51
Liivak K, Tillmann V. 24-hour blood pressure profiles in children with congenital adrenal hyperplasia on two different hydrocortisone treatment regimens. Journal of Pediatric Endocrinology & Metabolism 2009 511–517. (https://doi.org/10.1515/jpem.2009.22.6.511)
- 52↑
Hurtado-Gonzalez P, Mitchell RT. Analgesic use in pregnancy and male reproductive development. Current Opinion in Endocrinology, Diabetes, and Obesity 2017 225–232. (https://doi.org/10.1097/MED.0000000000000338)
- 53↑
Casteras A, De Silva P, Rumsby G, Conway GS. Reassessing fecundity in women with classical congenital adrenal hyperplasia (CAH): normal pregnancy rate but reduced fertility rate. Clinical Endocrinology 2009 833–837. (https://doi.org/10.1111/j.1365-2265.2009.03563.x)
- 54
Slowikowska-Hilczer J, Hirschberg AL, Claahsen-van der Grinten H, Reisch N, Bouvattier C, Thyen U, Cohen Kettenis P, Roehle R, Kohler B & Nordenstrom A, et al.Fertility outcome and information on fertility issues in individuals with different forms of disorders of sex development: findings from the dsd-LIFE study. Fertility & Sterility 2017 822–831. (https://doi.org/10.1016/j.fertnstert.2017.08.013)
- 55↑
Brannstrom M. Uterus transplantation. Current Opinion in Organ Transplantation 2015 621–628. (https://doi.org/10.1097/MOT.0000000000000246)
- 56↑
Hayashi K, Ogushi S, Kurimoto K, Shimamoto S, Ohta H, Saitou M. Offspring from oocytes derived from in vitro primordial germ cell-like cells in mice. Science 2012 971–975. (https://doi.org/10.1126/science.1226889)
- 57↑
Islam R, Lane S, Williams SA, Becker CM, Conway GS, Creighton SM. Establishing reproductive potential and advances in fertility preservation techniques for XY individuals with differences in sex development. Clinical Endocrinology 2019 237–244. (https://doi.org/10.1111/cen.13994)
- 58↑
van der Zwan YG, Biermann K, Wolffenbuttel KP, Cools M, Looijenga LH. Gonadal maldevelopment as risk factor for germ cell cancer: towards a clinical decision model. European Urology 2015 692–701. (https://doi.org/10.1016/j.eururo.2014.07.011)
- 59↑
Tack LW, Maris E, Looijenga LJ, Hannema SE, Audi L, Kohler B, Holterhus PM, Riedl S, Wisniewski A & Fluck CE, et al.Management of gonads in adults with androgen insensitivity: an international survey. Hormone Research in Paediatrics 2018 236–246. (https://doi.org/10.1159/000493645)
- 60↑
Cools M, Wolffenbuttel KP, Hersmus R, Mendonca BB, Kaprova J, Drop SLS, Stoop H, Gillis AJM, Oosterhuis JW & Costa EMF, et al.Malignant testicular germ cell tumors in postpubertal individuals with androgen insensitivity: prevalence, pathology and relevance of single nucleotide polymorphism-based susceptibility profiling. Human Reproduction 2017 2561–2573. (https://doi.org/10.1093/humrep/dex300)
- 61
Cools M, Drop SL, Wolffenbuttel KP, Oosterhuis JW, Looijenga LH. Germ cell tumors in the intersex gonad: old paths, new directions, moving frontiers. Endocrine Reviews 2006 468–484. (https://doi.org/10.1210/er.2006-0005)
- 62↑
Spoor JA, Oosterhuis JW, Hersmus R, Biermann K, Wolffenbuttel KP, Cools M, Kazmi Z, Ahmed SF, Looijenga LHJ. Histological assessment of gonads in DSD: relevance for clinical management. Sexual Development : Genetics, Molecular Biology, Evolution, Endocrinology, Embryology, and Pathology of Sex Determination and Differentiation 2018 106–122. (https://doi.org/10.1159/000481757)
- 63↑
Mouriquand PD, Gorduza DB, Gay CL, Meyer-Bahlburg HF, Baker L, Baskin LS, Bouvattier C, Braga LH, Caldamone AC & Duranteau L, et al.Surgery in disorders of sex development (DSD) with a gender issue: if (why), when, and how? Journal of Pediatric Urology 2016 139–149. (https://doi.org/10.1016/j.jpurol.2016.04.001)
- 64↑
Schweizer K, Brunner F, Gedrose B, Handford C, Richter-Appelt H. Coping with diverse sex development: treatment experiences and psychosocial support during childhood and adolescence and adult well-being. Journal of Pediatric Psychology 2017 504–519. (https://doi.org/10.1093/jpepsy/jsw058)
- 65↑
D'Alberton F, Vissani S, Ferracuti C, Pasterski V. Methodological issues for psychological evaluation across the lifespan of individuals with a difference/disorder of sex development. Sexual Development : Genetics, Molecular Biology, Evolution, Endocrinology, Embryology, and Pathology of Sex Determination and Differentiation 2018 123–134. (https://doi.org/10.1159/000484189)
- 66↑
Jesus LE. Feminizing genitoplasties: where are we now? Journal of Pediatric Urology 2018 407–415. (https://doi.org/10.1016/j.jpurol.2018.03.020)
- 67↑
Springer A, Tekgul S, Subramaniam R. An update of current practice in hypospadias surgery. European Urology Supplements 2017 8–15. (https://doi.org/10.1016/j.eursup.2016.09.006)
- 68↑
Szymanski KM, Whittam B, Monahan PO, Kaefer M, Frady H, Cain MP, Rink RC. Validation and preliminary results of the parental assessment of children's external genitalia scale for females (PACE-F) for girls with CAH. Urology 2019 132–137. (https://doi.org/10.1016/j.urology.2019.04.034)
- 69↑
Lee P, Schober J, Nordenstrom A, Hoebeke P, Houk C, Looijenga L, Manzoni G, Reiner W, Woodhouse C. Review of recent outcome data of disorders of sex development (DSD): emphasis on surgical and sexual outcomes. Journal of Pediatric Urology 2012 611–615. (https://doi.org/10.1016/j.jpurol.2012.10.017)
- 70
Kreukels BPC, Cohen-Kettenis PT, Roehle R, van de Grift TC, Slowikowska-Hilczer J, Claahsen-van der Grinten H, Linden Hirschberg A, de Vries ALC, Reisch N & Bouvattier C, et al.Sexuality in adults with differences/disorders of sex development (DSD): findings from the dsd-LIFE study. Journal of Sex & Marital Therapy 2019 1–18. (https://doi.org/10.1080/0092623X.2019.1610123)
- 71↑
van der Toorn F, de Jong TP, de Gier RP, Callewaert PR, van der Horst EH, Steffens MG, Hoebeke P, Nijman RJ, Bush NC & Wolffenbuttel KP, et al.Introducing the HOPE (hypospadias objective penile evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic appearance in hypospadias patients. Journal of Pediatric Urology 2013 1006–1016. (https://doi.org/10.1016/j.jpurol.2013.01.015)
- 72↑
Aho MO, Tammela OK, Somppi EM, Tammela TL. Sexual and social life of men operated in childhood for hypospadias and phimosis. A comparative study. European Urology 2000 95–100; discussion 101 . (https://doi.org/10.1159/000020107)
- 73↑
Weber DM, Landolt MA, Gobet R, Kalisch M, Greeff NK. The Penile Perception Score: an instrument enabling evaluation by surgeons and patient self-assessment after hypospadias repair. Journal of Urology 2013 189–193. (https://doi.org/10.1016/j.juro.2012.08.178)
- 74↑
Weber DM, Schonbucher VB, Landolt MA, Gobet R. The Pediatric Penile Perception Score: an instrument for patient self-assessment and surgeon evaluation after hypospadias repair. Journal of Urology 2008 1080–1084; discussion 1084 . (https://doi.org/10.1016/j.juro.2008.05.060)
- 75
Crouch NS, Liao LM, Woodhouse CR, Conway GS, Creighton SM. Sexual function and genital sensitivity following feminizing genitoplasty for congenital adrenal hyperplasia. The Journal of Urology 2008 634–638. (https://doi.org/10.1016/j.juro.2007.09.079)
- 76↑
Bennecke E, Thyen U, Gruters A, Lux A, Kohler B. Health-related quality of life and psychological well-being in adults with differences/disorders of sex development. Clinical Endocrinology 2017 634–643. (https://doi.org/10.1111/cen.13296)
- 77↑
Sanders C, Hall J, Sanders C, Dessens A, Bryce J, Callens N, Cools M, Kourime M, Kyriakou A & Springer A, et al.Involving individuals with disorders of sex development and their parents in exploring new models of shared learning: Proceedings from a DSDnet COST Action Workshop. Sexual Development 2018 12 225-231. (https://doi.org/10.1159/000490081)
- 78↑
Hyde JS, Bigler RS, Joel D, Tate CC, van Anders SM. The future of sex and gender in psychology: five challenges to the gender binary. American Psychologist 2019 171–193. (https://doi.org/10.1037/amp0000307)
- 79↑
Pasterski V, Mastroyannopoulou K, Wright D, Zucker KJ, Hughes IA. Predictors of posttraumatic stress in parents of children diagnosed with a disorder of sex development. Archives of Sexual Behavior 2014 369–375. (https://doi.org/10.1007/s10508-013-0196-8)
- 80↑
Magritte E. Working together in placing the long term interests of the child at the heart of the DSD evaluation. Journal of Pediatric Urology 2012 571–575. (https://doi.org/10.1016/j.jpurol.2012.07.011)
- 81↑
Liao LM, Wood D, Creighton SM. Parental choice on normalising cosmetic genital surgery. BMJ 2015 h5124 . (https://doi.org/10.1136/bmj.h5124)
- 82
Cools M, Simmonds M, Elford S, Gorter J, Ahmed SF, D'Alberton F, Springer A, Hiort O & Management Committee of the European Cooperation. Response to the Council of Europe Human Rights Commissioner’s issue paper on human rights and intersex people. European Urology 2016 407–409. (https://doi.org/10.1016/j.eururo.2016.05.015)
