Disorders of Sexual Differentiation

  • Overview text

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    GEMS treats the medical and psychosocial issues of infants, children, adolescents and young adults with disorders of sexual differentiation.
    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 5
    Boston MA 02115
     617 355 6116
     fax: 617-730-0194

    »
    The Center offers testing, long-term medical care, and will work with you to decide the best approach for treatment.
    Boston Children's Hospital 
    300 Longwood Ave.
    Boston MA 02115
     617-355-7648
     fax: 617-730-0186


  • At Boston Children's Hospital , we understand that a diagnosis of a disorder of sexual differentiation (DSDs) can cause much anxiety. You probably have a lot of questions and uncertainty about your child’s sexuality and health. Our team of clinicians in the Disorders of Sexual Development (DSD) and Gender Management Service (GeMS) provide some answers to those questions here.  When you meet with our team of experts, they’ll be able to explain your child’s condition and options in more detail.

    Remember that seeking out information is not only necessary but also empowering—it allows you to partner with your child’s care providers to make the best decisions for your child and your family.

    What are DSDs?

    • DSDs describe a wide range of conditions in which development of the sex organs does not occur as it normally would.
    • These conditions involve mild to significant variations in reproductive organ development, sex development and gender identity.

    What are the different types of DSDs?

    The most common DSDs detected in newborns are:

    Congenital adrenal hyperplasia 

    • Congenital adrenal hyperplasia (CAH) genetic disorder of the adrenal glands. If your child has this condition, it means that their adrenal glands don’t produce enough of the vital hormones cortisol and aldosterone. As a result, his body produces too much androgen.
    • Females born with this condition are typically born with an enlarged clitoris, but with normal internal reproductive structures.
    • Males born with this condition have normal genitals at birth, but may develop a large penis, smaller testes and a deeper voice well before puberty.
    • Treatment for females may involve hormone replacement therapy, reconstructive surgery and psychological support. For males, medical treatment is indicated.

    Mixed gonadal dysgensis

    • Mixed gonadal dysgenesis (MGD) is a disorder of sexual differentiation in which a chromosomal abnormality causes a child to be born with two different gonads:  an undescended testis and a dysgenetic (malformed) “streak” gonad.
    • A child with MGD has an undescended testicle on one side and a dysgenetic (improperly developed) gonad on the opposite side. The two different gonads can’t produce normal sex hormones, resulting in malformed sex organs.
    • Gender assignment is important for treatment purposes as well as the emotional well being of children as they grow older and remains a crucial part of the treatment for MGD. However, the complexity of treatment varies depending on your child’s exact anatomy.

    Although less common, other types of DSDs include:

    Impaired testicular development

    • Impaired testicular development occurs either because of an inherited genetic defect or for an idiopathic (unknown) reason.
    • Typically, a child’s body is unable to produce testosterone, which prevents the testicular structures from developing. Impaired testicular development is not the same as having an undescended testicle.
    • Treatment may involve surgery. The child’s clinician will advise and work with the family on other gender and related considerations.

    Androgen insensitivity syndrome (AIS):

    • AIS is an inherited genetic disorder in which a child is born with chromosomes and gonads  (with one X chromosome and one Y chromosome), but the cells in the body do not respond to the male sex hormone androgen. As a result, the child displays female characteristics despite being genetically male.
    • AIS can be either complete (in which case the child appears completely female), or incomplete (in which case, the external appearance may be ambiguous).
    • Treatments can include removal of the undescended testes (to eliminate the risk of cancer) and taking estrogen replacement medication.

    Causes

    What causes disorders of DSDs?

    Sex development starts at the time of conception and continues through late adulthood. The normal pattern of sexual development looks like this:

    Chromosomes and gonads:

    Gonads are the body’s primary sex organs. They form according to a specific chromosomal pattern:

    • The mother’s egg and the father's sperm start out with 23 chromosomes during conception. During this time, a child inherits 23 chromosomes from each parent, ending up with a total of 46 chromosomes.
    • Normally, the egg from the mother contributes one X chromosome and the sperm form the father contributes either one X chromosome or one Y chromosome.
    • A child is born female if she inherits two X chromosomes (XX). A child is born male if he inherits one X chromosome and one Y chromosome (XY).
    • As a result of this chromosomal pattern, boys develop gonads called testicles and females develop gonads called ovaries.

    Hormones

    • The primary function of the gonads is producing hormones. Normally, testes produce the male hormone testosterone and ovaries produce the female hormone estrogen.
    • These hormones aid in the formation of sex organs. The testosterone produced from the male testes drive the formation of a penis. The estrogen produced by female ovaries result in the formation of a vagina.

    Sexual development in children with DSDs

    With so many stages of sex development, there are a lot of opportunities for a fetus to take a path that not typical for a boy or a girl. When an atypical path of development is taken, the resulting condition is known as a “disorder of sexual development”.

    There are several ways this can happen:

    • Some disorders are genetic (chromosome variations).
    • Some are present at birth (congenital) but not genetic.
    • Some are variations in psychosocial development.
    • DSDs can also be idiopathic, meaning they have no identifiable cause.

    Symptoms

    What are the symptoms of DSDs?

    The symptoms of a DSD depend on what type of condition your child has.

    • In most cases, children with DSDs have  genitalia that are atypical in appearance. This may include ambiguous genitalia or dysgenetic (malformed) gonads.
    • DSD can also be limited to a child’s internal structures.

    What does “ambiguous genitalia” mean?

    • Ambiguous genitalia refers to sexual organs that aren't well formed or aren't clearly male or female.
    • At conception, a fetus's gender is already determined based on the 23rd pair chromosome it inherited from the parents.
    • Females have two X chromosomes and males have an X and a Y chromosome. Even though the gender is set, the fetal tissue that will eventually become the female ovaries or male testes (gonads) has not yet begun to take its form.
    • If the hormonal process that causes that tissue to become male or female is disrupted over the following weeks, ambiguous genitalia can develop.

    What causes ambiguous genitalia?

    The biology behind ambiguous genitalia can be hard to understand. Breaking it down in the following steps can make it easier:

    • The sexual organs of males and females develop from the same fetal tissue. The same tissue that becomes a penis in a male becomes a clitoris in a female.
    • The main factor controlling the next step is male hormones. The presence of male sex hormones causes male organs to develop and the absence of male hormones causes female organs to develop.
    • Without enough male hormones, a genetic male will develop ambiguous genitalia. Likewise, a genetic female will develop ambiguous genitalia if male hormone is present.

    What are the symptoms of ambiguous genitalia?

    Your obstetric team will most likely be the first ones who notice the ambiguous genitalia. They may see the following:

    Characteristics of ambiguous genitalia in genetic females include:

    • an enlarged clitoris, or what appears to be a small penis
    • a concealed vagina

    Characteristics of ambiguous genitalia in genetic males include:

    • an abnormally small penis with the urethral opening nearer to the scrotum
    • no recognizable male genitalia in the most severe cases
    • the absence of both testicles in what appears to be the scrotum

    What is the long-term outlook for a child with ambiguous genitalia?

    With proper medical management, most children with ambiguous genitalia will lead healthy and normal lives.  Sex assignment  and corrective surgery are necessary in allowing your child to lead a fairly normal life as a boy or a girl. As a child grows up and enters puberty, there is a slight chance that they will identify with a sex other than the one they were assigned. In this case, a gender transition may be necessary. It’s recommended that physicians wait until the child is around 16 years old before beginning the hormone therapy process involved in a transition.

    FAQs

    Q: What’s the difference between DSDs and “intersex disorders”?

    A: DSDs used to be called “intersex disorders”. The name was changed to DSD to prevent any confusion or limiting definitions.

    Q: Should my child get corrective genital surgery?

    A: After your child is diagnosed with a DSD, you should have a discussion with your family and your child’s doctor about optimal management, including sex assignment. Deciding on a sex assignment depends on the anatomic findings, so it will vary from child to child.

    Q: When should I consider treatment?

    A: After an accurate diagnosis is made, parents discusses with your family and your child’s doctor about treatment options. Parents are encouraged to take their time when consideration treatment options and not make any immediate decisions. To avoid gender confusion, it’s best to perform corrective surgery when the child is very young.  At Children’s, our doctors usually perform the reconstructive surgery when a child is about 6 months old, which reduces the risks of anesthesia.

    Q: Will my child be able to have children?

    A: Whether or not individuals with DSD are able to have biological children depends on what condition they have. In general, people with DSDs are not fertile or have very low fertility rates.

    Q: What’s the difference between gender and sex?

    A: Sex is a biological term that describes someone as being either “male” or “female”. Sex refers to sex chromosomes and sex organs.

    Gender refers to attitudes, behaviors and personality characteristics that are typically associated with each sex. Gender identity is how a person identifies with masculine or feminine traits. Gender is different from sex because sometimes a person can identify with a gender that is opposite from his or her biological sex.

    Q: How can I help my child?

    A: Emotional support and acceptance are the best things parents can offer a child who has a DSD. Having a condition that doesn’t fit with “social norms” can be difficult, and many children with a DSD may feel ashamed or become overly focused on the appearance of their genitals. To help your child from feeling stigmatized, talk openly and honestly with him about his medical condition. Encourage him to voice any questions or concerns and avoid pushing him into a certain gender. Peer support and psychosocial counseling is key in helping children and their families come to terms with the diagnosis.

     If you are having trouble coping with your child’s condition, we offer many support services that can help you to develop parenting strategies and feel less anxious.

    Questions to ask your doctor

    If your child has just been diagnosed with a DSD, you probably have a lot of questions on your mind before meeting with your child’s doctor. At the appointment, it can be easy to be overwhelmed with information and forget the questions you wanted to ask.

    A lot of parents find it helpful to jot down questions beforehand. That way, when you talk to your child’s clinician, you can be sure that all your concerns are addressed. Remember that physicians are open to learning from families too. Attend conferences, read up on updated materials and don’t be afraid to share what you have learned.

    Some questions you might ask include:

    • What kind of experience do you have taking care of children with DSDs?
    • What treatment plan do you recommend?
    • How should I talk to my child about this condition?
    • How should I explain my child’s DSD to others?
    • What does my child’s long-term treatment plan involve?
    • What is the follow up care plan?
    • What other resources can you point me to for more information?

     

    Born with the wrong body
    Norman Spack, MD, co-director of Boston Children’s GeMS Gender Management Service Clinic, talks about gender identity in the online version of abc’s 20/20.
  • At Boston Children's Hospital, we know that first step in treating a child with disorders of sexual differentiation (DSDs) is forming an accurate diagnosis. A child can be diagnosed with a DSD as early as the newborn period and as late as adulthood.

    How are DSDs diagnosed?

    When children with DSDs also have ambiguous genitalia, the disorder can be diagnosed at birth.  If doctors suspect a DSD on the initial newborn exam, pediatric specialists in urology and endocrinology will examine your baby right away.

    These tests may include:

    • Pelvic ultrasounds to look for female reproductive structures, such as a cervix, fallopian tubes and a uterus.
    • Blood tests to determine the level of sex hormones in the blood.
    • Gonadal biopsy to assist in gender assignment
    • Karyotyping, a type of analysis that allows doctors to determine the genetic sex of the baby.
    • Genitogram, a type of test that allows doctors to visualize the outline of the reproductive structures.

    What happens after a diagnosis has been made?

    After a possible DSD is identified, your child’s doctor will explain any medical concerns and make sure that you understand the results of the tests. If the child is old enough to be aware of the medical attention he is receiving, it’s important to explain what is happening in terms he can understand. 

  • At Boston Children's Hospital, we take a multidisciplinary approach in treating your child's disorder of sexual differentiation (DSD). Our team will work together to develop the best comprehensive treatment plan for your child's unique condition. You, as parents, will be involved every step of the way.

    How are DSDs treated?

    The treatment options for DSDs vary depending on the complexity of your child's disorder. The medical treatments may include hormone replacement therapy, surgery, and psychosocial support.

    Surgery

    Surgical interventions depend on what type of DSD your child has. In some cases, surgery may be required. In other cases, surgery remains an elective (optional) procedure.

    Situations where surgery is required:

    • Corrective surgery would be required forconditions where ambiguous genitalia interfered with a child's sexual and reproductive function. In this case, appropriate sex organs may need to be removed or created in order for them to function properly.
    • Surgery is also required for conditions like mixed gonadal dysgenesis, where sex assignment is needed.This sex assignment is important for treatment purposes as well as the emotional well being of the child as they grow older.
    • If a gonad is cancerous or is at risk for becoming cancerous, removal of the undescended testis is a serious consideration.

    Situations where surgery may be elective:

    Reconstructive surgery to improve the aesthetic appearance of the genitals is often elective.

    • Girls who are born with a condition that causes male-appearing genitalia, like congenital adrenal hyperplasia, often undergo reconstructive surgery to reduce the clitoral size and make the vaginal opening better defined.
    • Male reconstructive genital surgery is used to straighten the penis and move the urethra to the tip of the penis.

    Hormone replacement therapy (HRT)

    • In terms of lifelong management of DSDs, the goal is to keep hormone levels at a normal level.
    • In order to do this, your child may need to take a daily form of cortisol medication, such as:
      • dexamethasone
      • fludrocortisone
      • hydrocortisone
    • Girls may need hormonal therapy throughout their lives, which is given as a daily pill.

    Coping & support

    Children's resources for families:

    • At Boston Children's Hospital's Gender Management Service (GeMS) Clinic we help families deal with the psychosocial issues of raising infants, children, adolescents and young adults with disorders of sexual differentiation (DSDs). Our expert physicians and clinical staff work closely with your child and your family to find the treatment that works best for everyone involved.

    Children's Coping Program helps children who are being treated on an outpatient basis at the hospital—as well as their families—understand and cope with their feelings about:

    • being sick
    • facing uncomfortable procedures
    • handling pain
    • taking medication
    • preparing for surgery
    • changes in friendships and family relations
    • managing school while dealing with an illness
    • grief and loss

    Visit the Behavioral Medicine and Coping Clinic program page or call us at 617-355-6688 to learn more.

    For teens

    Adolescence can be stressful—even for physically healthy teens. Having a condition like MGD during adolescence further complicates life for teenagers.

    • Support for teen boys: As a boy with a DSD reaches adolescence, he may look and feel different from other males his age. Young Men's Health (YMH) is a website that provides health information for teen boys and young men.
    • Support for teen girls:  Girls with a DSD can experience their own set of difficulties when they enter puberty and may exhibit more masculine behavior than other girls their age. The Center For Young Women's Health offers the latest gender-specific information about sexual and emotional health.
    • The Medical Coping Team at Boston Children's Hospital works with teens and their families to help them adjust to the stress caused by chronic illness. Our experienced team of pediatric psychologists, psychiatrists and other mental health professionals provide effective, compassionate evaluation, education, counseling and therapy to help teens cope.

    Other resources

    Please note that neither Children's nor the Gender Management Service Clinic at Children's unreservedly endorses all of the information found at the sites listed below.

    • Androgen Insensitivity Syndrome Support Group (AISSG) provides information on Androgen Insensitivity Syndrome (AIS) and similar conditions.
    • CARES Foundation, Inc. provides education and research for Congenital Adrenal Hyperplasia while providing the resources and the latest information available for managing life with CAH.
  • Research & Innovation

    Years ago, babies born with ambiguous genitalia were routinely "assigned" a gender by their physicians, and underwent treatment to match that assignment. Today, decision-making is much more individualized and is done in close consultation with the family.

    Beyond evaluating, diagnosing and treating infants, children and adolescents with disorders of the genital and urinary organs, The Gender Management Service (GeMS) Clinic at Boston Children's Hospital is also looking to the future. Our physicians and researchers are leading a number of studies and trials that hold great promise in the detection and treatment of this condition.

    Find out about clinical trials happening at Children's.

    New guidelines for teens with Gender Identity Disorder
    Norman Spack, MD, co-director of Children’s Gender Management Service Clinic, is a part of the team that developed groundbreaking new guidelines on how to treat children with Gender Identity Disorder. Read more about what Dr. Spack has to say about these gender identity guidelines and treating children with Gender Identity Disorder.
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