THE INTERSEXED PATIENT

There are at present two opposing points of view on problems of dealing with the intersexed patient (not the typical homosexual or transvestite) who has clearcut anatomical or biochemical qualities of the opposite sex. The first is that in the growing child or adult coming for treatment, the sex the patient should adopt is the summation of somatic sex. The other is that the sex role should be assigned according to the predominant psychological identification already present.A case history of a middle-aged pseudohermaphrodite, castrated in youth but raised from birth as a female and living thus in “homosexual” relations with women until examined and interviewed at UCLA Medical Center is presented to illustrate the psychological problems in sexual identity with which the patient had to cope.Psychiatric investigation revealed how confused the patient''s sex identity was until treatment by a team consisting of psychiatrist, psychologist and endocrinologist permitted the patient, even at so late a date, finally to establish what his gender is. The patient was able, despite early rearing as a female and a castrating operation, to swing to a more masculine identification. This was possible because of some uncertainty of sexual role from an early age.     

Are Sex Drive and Hypersexuality Associated with Pedophilic Interest and Child Sexual Abuse in a Male Community Sample?

Although much is currently known about hypersexuality (in the form of excessive sexual behavior) among sexual offenders, the degree to which hypersexual behavior is linked to paraphilic and especially pedophilic interests in non-forensic populations has not been established. The purpose of the present study was to elucidate the associations between total sexual outlets (TSO) and other sex drive indicators, antisocial behavior, pedophilic interests, and sexual offending behavior in a large population-based community sample of males. The sample included 8,718 German men who participated in an online study. Hypersexual behavior as measured by self-reported TSO, self-reported sex drive, criminal history, and pedophilic interests were assessed. In moderated hierarchical logistic regression analyses self-reported contact sexual offending against children was linked to sexual fantasizing about children and antisociality. There was no association between aggregated sex drive, and sexual abusive behaviour in the multivariate analyses. In contrast, self-reported child pornography consumption was associated with sex drive, sexual fantasies involving children, and antisociality. Nevertheless, in clinical practice an assessment of criminal history and pedophilic interests in hypersexual individuals and vice versa hypersexuality in antisocial or pedophilic men should be considered as particularly antisociality and pedophilic interest are important predictors of sexual offending against prepubescent children.     

A Genome-Wide Survey of Sexually Dimorphic Expression of Drosophila miRNAs Identifies the Steroid Hormone-Induced miRNA let-7 as a Regulator of Sexual Identity

MiRNAs bear an increasing number of functions throughout development and in the aging adult. Here we address their role in establishing sexually dimorphic traits and sexual identity in male and female Drosophila. Our survey of miRNA populations in each sex identifies sets of miRNAs differentially expressed in male and female tissues across various stages of development. The pervasive sex-biased expression of miRNAs generally increases with the complexity and sexual dimorphism of tissues, gonads revealing the most striking biases. We find that the male-specific regulation of the X chromosome is relevant to miRNA expression on two levels. First, in the male gonad, testis-biased miRNAs tend to reside on the X chromosome. Second, in the soma, X-linked miRNAs do not systematically rely on dosage compensation. We set out to address the importance of a sex-biased expression of miRNAs in establishing sexually dimorphic traits. Our study of the conserved let-7-C miRNA cluster controlled by the sex-biased hormone ecdysone places let-7 as a primary modulator of the sex-determination hierarchy. Flies with modified let-7 levels present doublesex-related phenotypes and express sex-determination genes normally restricted to the opposite sex. In testes and ovaries, alterations of the ecdysone-induced let-7 result in aberrant gonadal somatic cell behavior and non-cell-autonomous defects in early germline differentiation. Gonadal defects as well as aberrant expression of sex-determination genes persist in aging adults under hormonal control. Together, our findings place ecdysone and let-7 as modulators of a somatic systemic signal that helps establish and sustain sexual identity in males and females and differentiation in gonads. This work establishes the foundation for a role of miRNAs in sexual dimorphism and demonstrates that similar to vertebrate hormonal control of cellular sexual identity exists in Drosophila.     

Selection and Maintenance of Sexual Identity in the Drosophila Germline

Unlike sex determination in the soma, which is an autonomous process, sex determination in the germline of Drosophila has both inductive and autonomous components. In this paper, we examined how sexual identity is selected and maintained in the Drosophila germline. We show that female-specific expression of genes in the germline is dependent on a somatic signaling pathway. This signaling pathway requires the sex-non-specific transformer 2 gene but, surprisingly, does not appear to require the sex-specific genes, transformer and doublesex. Moreover, in contrast to the soma where pathway initiation and maintenance are independent processes, the somatic signaling pathway appears to function continuously from embryogenesis to the larval stages to select and sustain female germline identity. We also show that the primary target for the somatic signaling pathway in germ cells can not be the Sex-lethal gene.     

Structural and functional sex differences in the human hypothalamus

Sex differences in the brain may be the basis not only for sex differences in reproduction, gender identity (the feeling of being male or female), and sexual orientation (heterosexuality vs homosexuality), but also for the sex difference in prevalence of psychiatric and neurological diseases ( Swaab and Hofman, 1995 ). In this brief article we discuss a few examples of structural and functional sex differences in the human brain.     

Habilitation of Patients with Congenital Malformations Associated with Thalidomide: Psychiatric and Psychological Aspects

Nearly 100 cases of congenital malformations associated with thalidomide ingestion by the mother have been reported in Canada to the Department of National Health and Welfare. Depression and selfcastigation have been the specific psychiatric reactions noted, particularly in the mother. In most cases it is preferable psychologically for the parents and the child if the child is kept at home rather than placed in an institution. Parents should be fully informed concerning the child''s prognosis for future development. Most of the children followed up for about two years showed no intelligence defects. A prosthesis, if required, should be applied early (at three to six months) so that it may become a part of the child''s body-image, but it should not interfere with play activities. Assessment by a psychiatrist and a psychologist is indicated at about six months.     

DIAGNOSIS OF DEAFNESS IN PRESCHOOL CHILDREN

Hearing and speech disorders in children are often not due to actual defects in the ear or speech organs. Supposed loss of hearing and speech can occur in children who hear well but who cannot identify the words, understand their meaning or express them because of damage to certain brain centers and nerve pathways in conditions called aphasia, psychic disorders and mental deficiency.The child uses his special senses (hearing, sight, touch, feel and smell) to establish contact with his environment and of these senses, hearing is most important because it helps to build the best avenue of communication with his immediate world.As the deafened child can usually be helped by treatment, it is necessary to make a correct diagnosis early in order that the proper measures may be instituted in the first five years of life.     

SOME VIEWPOINTS ON CHILD PSYCHIATRY

There is a great tendency in recent years to seek psychiatric answers to well-nigh all kinds of child problems. This tendency is seriously questioned. The average child has splendid capacities to solve his own growth problems, within the limits of home, school, neighborhood. Evidence accumulates that the average parent who seeks counsel has done a rather respectable job; that in his fear of setting limits because of “how the child will feel,” there is more of psychological threat to the child than in daring to comfortably move ahead and make some mistakes.Psychiatric treatment of a child implies that the child is unable to meet situations as adequately as other children. Such treatment should be reserved, in the main, for use in situations in which the psychiatrist and parents are willing to underwrite the implications of treatment. Treatment aimed at the vague goal of making the child “happier” is dubious. Treatment by a psychiatrist is presumably medical treatment and carries with it the advantages and disadvantages inherent in this fact. When given without carefully defining the reasons for it and the goals at which it is aimed, within medical framework, it is potentially an undesirable procedure.     

Intersexual Births: The Epistemology of Sex and Ethics of Sex Assignment

This article aims to analyse a possible manner of approaching the birth of intersexual children. We start out by summing up what intersexuality is and how it is faced in the dominant clinical practice (the “treatment paradigm”). We then argue against this paradigm, in favour of a postponement of genital surgery. In the second part of this paper, we take into consideration the general question of whether only two existing sexes are to be recognized, arguing in favour of an expansion of sex categories. In the third part, we illustrate the reasons supporting provisional sex attribution: the child’s best interest and respect for their developing moral autonomy. This position aims to increase the child’s well-being and self-determination, limiting parents’ freedom to take decisions on behalf of others, in particular, those decisions concerning basic aspects of their children’s personal identity.     

Identité masculine et transsexualisme

Transsexualism is a phenomenon of our culture. In the past, there were men and women who could not accept their innate sex. What is new is linked to our modern medical technology which offers patients a so-called «change of sex» using hormones and surgery; in fact it is a change in appearance, allowing the individual to «pass» as a member of the other sex. Some societies had and still have a social status for a third gender, but our transsexuals do not want to be treated as members of a third gender, they want to belong to the other gender Male-to-female and female-to-male transsexuals have the same mental functioning, characterized by splitting and denial. But there are differences, in part because society is more intolerant of feminine behaviors in men than of masculine behaviors in women. Male-to-female transsexualism includes a subgroup of subjects who, after failing in school, are unable to earn their living and live on welfare, even after surgical sex reassignment. We have learned from the study of intersexed and transsexual subjects that the feeling of belonging to a gender is a belief, a construction, in which psychological factors (interactions between the parents, the environment and the child) play an important role. Masculine or feminine identities have their roots in the sexual difference, but they are defined by each culture. A man is a male who accepts at least part of his culture’s stereotypes regarding masculinity. Even if biological factors play a role, they cannot explain the whole of gender identity and sexual orientation.     

Psychiatric problems in children with hemiplegia: cross sectional epidemiological survey.

OBJECTIVE--To examine the prevalence and predictors of psychiatric problems in children with hemiplegia. DESIGN--Cross sectional questionnaire survey of an epidemiological sample with individual assessments of a representative subgroup. The questionnaire survey was repeated on school age subjects four years later. SUBJECTS--428 hemiplegic children age 2 1/2-16 years, of whom 149 (aged 6-10 years) were individually assessed. MAIN OUTCOME MEASURES--Psychiatric symptom scores and the occurrence of psychiatric disorder. RESULTS--Psychiatric disorders affected 61% (95% confidence interval 53% to 69%) of subjects as judged by individual assessments and 54% (49% to 59%) and 42% (37% to 47%) as judged from parent and teacher questionnaires, respectively. Few affected children had been in contact with child mental health services. The strongest consistent predictor of psychiatric problems was intelligence quotient (IQ), which was highly correlated with an index of neurological severity; age, sex, and laterality of lesion had little or no predictive power. CONCLUSION--Though most hemiplegic children have considerable emotional or behavioural difficulties, these psychological complications commonly go unrecognised or untreated. Comprehensive health provision for children with chronic neurodevelopmental disorders such as hemiplegia should be psychologically as well as physically oriented.     

Gender identity and recalled gender related childhood play-behaviour in adult individuals with different forms of intersexuality

The concept of intersexuality subsumes a wide variety of phenomena with very specific underlying causes. In all these cases, an untypical development takes place during the prenatal sex differentiation process becoming clinically manifest, either at, or soon after birth or at the time of puberty. It subsumes conditions in which biological sexual characteristics (e.g. chromosomal sex, gonadal sex, hormonal sex, morphological sex) differ from each other and one person cannot easily be assigned to one sex. One of the main goals of medical treatment of persons with intersex-syndroms is the development of a stable gender identity. Over the last few years, sex (and gender) assignment of persons with different forms of intersexuality has become a much discussed topic. An interesting--and very obviously observable--variable that was brought in connection with sex assignment is gender related childhood play behaviour. The purpose of the presented study is to examine 37 persons with different forms of intersexuality (disturbances of androgen biosynthesis, partial and complete androgen insensitivity, gonadal dysgenesis with 46,XY and congenital adrenal hyperplasia with 46,XX) with regard to gender identity and gender role behaviour in childhood. Not all subjects in the study group had developed a clear female or male gender identity. In contrast to previous studies, some persons with CAIS did not recall distinguished female childhood play behaviour and these persons did not show a clear female gender identity. In contrast to results from other studies, the CAH-affected girls in this study did not seem to recall masculinized behaviour. Further research is needed to guarantee better psychosexual development with good quality of life in individuals with intersexuality.     

The Association of Maternal Psychopathology and Family Socioeconomic Status with Psychological Problems in Obese Children

In an earlier study we found parental psychiatric symptoms to be a better correlate of behavioral problems in obese children than either child or parental obesity. This study sought to extend this research by assessing the association of general maternal distress, specific maternal psychopathology, family socioeconomic status and child obesity with the psychological problems of 152 children seeking treatment for obesity in two cohorts. Child psychological problems were measured using the Child Behavior Checklist/4–18 (CBCL) in each cohort. In sample 1 maternal general psychiatric symptoms were measured using the Cornell Medical Index (psychiatric subscales) and the Inventory of Interpersonal Problems whereas specific psychopathology was assessed with the Beck Depression Inventory and the Bulimia Test. In sample 2 the Symptom Checklist-90 and Binge Eating Scale provided general and specific measures of psychopathology. In the combined sample, 58% percent of the boys and 44% of the girls met criteria on at least one CBCL behavioral problem scale, with Social Problems the most prevalent problem in both boys and girls. For both samples, child obesity did not account for any variance in child psychosocial problems beyond that accounted for by maternal psychopathology and family SES. Family SES accounted for a significant increment in variance in child behavioral problems in only two scales. This study systematically replicates previous research, adding support for a broader conceptualization of factors that influence psychological problems in obese treatment-seeking children than one which focuses on child obesity.     

Darwin's sexual selection: Understanding his ideas in context

Darwin's writings need to be seen in their fullness, as opposed to quote-mining individual sentences without the context of his passages. Sometimes Darwin wrote at length, apparently favorably, about ideas that he subsequently undermined, replacing them with a more integrative view that reflected his own broad compass. Darwin understood that nature is not simple, that not all members of a group may have evolved under the same selective regime, and that variation of all kinds is fundamental to selection in its several forms. Sexual selection requires sexual dimorphism; it is not centred on variation within sexes but on selection for the ability to acquire mates. “Mutual sexual selection” was rejected by Darwin for every species except humans. Mating success is not a matter of mere numbers but of the transmission of the most attractive features to the opposite sex. The term “sexual selection” should only be used when one sex uses a feature not present in the other sex to attract mates or repel rivals for mates.     

Divergence or disorder?: the politics of naming intersex

The conditions once known under the umbrella terms intersex and hermaphroditism are now generally being called disorders of sex development in medical settings. The terms might seem synonymous, but in fact there are significant differences with controversial consequences. Hermaphroditism, an older term that can still be found in many medical writings, is vague, demeaning, and sensationalistic, conjuring mythic images of monsters and freaks. In the 1990s, activists advocated intersex to describe discordance between the multiple components of sex anatomy, but that word alienated many parents of affected children, as it suggests a self-conscious alternative gender identity and sexuality. Disorders of sex development also refers to intersex, but it deemphasizes the identity politics and sexual connotations associated with intersex, avoids the degradation associated with hermaphrodite, and instead highlights the underlying genetic or endocrine factors that cause prenatal sex development to take an unusual path. I argue that using disorder is problematic, because it implies medical conditions in need of repair, when some intersex anatomies, though atypical, do not necessarily need surgical or hormonal correction. I advocate a less pathologizing new term, divergence of sex development, that might reduce some of the conflict over nomenclature and satisfy intersex people, their parents, and their doctors.     

Psychosocial stress and abdominal pain in adolescents

Children and adolescents may express psychiatric symptoms via somatic complaints. Likewise, children with chronic somatic illnesses are likely to experience psychiatric sequelae. We report three cases of adolescents who were admitted to general paediatrics services for abdominal pain and/or nausea and vomiting with a negative medical workup. In each case, a clear psychosocial stressor was evident. It is possible that somatic symptoms without clear medical causes may reflect psychosocial stress, but it is difficult to discern whether the psychosocial issues preceded the somatic complaints or were a result of them. Making an accurate diagnosis is difficult, and broaching such a subject with patients and their families is a delicate matter. More research is needed to determine appropriate screening tools for identifying cases where psychosocial stress may play a relevant role in symptom presentation, as well as potential treatment modalities for such cases.     

Génétique et infertilité masculine: données actuelles

Intracytoplasmic sperm injection (ICSI) and testicular biopsies (TESE) have revolutionized the treatment of male infertility, introducing a risk of an increased frequency of genetic defects in the offspring. These risks and their consequences must therefore be evaluated when proposing ICSI to an infertile man. Karyotype and molecular analysis should be performed to detect any genetic defects responsible for male infertility. Y microdeletion screening is important, not only to define the aetiology of spermatogenic failure, but also to provide information allowing a more appropriate management of both the infertile male and his future male child. Genetic counselling is then advised before deciding to attempt ICSI.     

Does surgical genitoplasty affect gender identity in the intersex infant?

There is no clear-cut answer to the question of whether surgical genitoplasty affects gender identity in the intersex infant. The debate centres around which is more important for the development of gender identity: the biological sex of a child or the sex in which a child is reared. We believe that the surgical achievement of a phenotype concordant with the sex of rearing is a tremendous help to the parents of an intersex infant. We do not consider that the 'neutral' upbringing of a child with ambiguous genitalia is a feasible option, first because of the parents' distress which prevents them from raising their child normally and second because in most cultures around the world gender variants are not treated as equals. A neutral upbringing may induce psychosocial consequences that are more pernicious than carefully considered neonatal sex attribution and concordant surgical genitoplasty.