Variations of sex development: The first German interdisciplinary consensus paper.

INTRODUCTION: The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly 'feminizing' elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female. Protests by advocacy groups for the most part as well as the results of outcome studies have shown that the development of affected persons may be very different to what has been expected and often does not result in the intended clear female or male gender identity as had been intended. It, therefore, seemed a matter of urgency to implement this new awareness as well as the ethical and personal human rights perspectives in the recommendations for the medical and psychosocial management of diverse sex development (DSD) in the future. STUDY DESIGN: In 2012, an interdisciplinary group of German academics engaged in the field of DSD decided to work on a consensus paper for this topic. It involved the participation of all faculties and non-scientific groups dealing with DSD, in particular advocacy and service-user groups. In a structured consensus, process recommendations were developed based on scientific literature as well as personal experiences of clinicians and affected individuals. RESULTS: Finally, 37 recommendations were agreed on. The strength of consensus is reflected in the degree of agreement as expressed in percentages. CONCLUSION: The introduction of the consensus paper reflects on the emerging paradigm shift and the necessity for a more open view of gender within society. The paper is intended to aid the performance of appropriate diagnostics in DSD-affected newborns and especially to help parents and affected persons cope with the biological and social consequences of DSD. With regard to medical or surgical therapy, it gives information about the most recent treatment trends.

A network analysis of body satisfaction of people with gender dysphoria.

In gender dysphoria (GD), much of the experienced distress results from body dissatisfaction. The current study analyzed the configuration of body satisfaction in trans men and women using network analysis. In total, 485 individuals diagnosed with GD from four European countries, applying for medical treatment, filled out the Body Image Scale for Transsexuals. A six-factor model reflecting different body areas was confirmed via confirmatory factor analysis. A further configuration of body satisfaction was modelled using correlation network analysis techniques in R. Genital dissatisfaction showed limited connection with other body areas in comparison to other subscales. Body characteristics influencing social gender recognition were most centrally involved in body (dis)satisfaction in both natal sexes. In trans women these characteristics were related mostly to voice and hair, whereas in trans men these characteristics were related to muscularity and posture. Focusing on these socially influential body characteristics may provide important targets for transgender healthcare.

[Intersexuality not transsexuality. Delineation, new results, and proposals]. / Intersexualität nicht Transsexualität. Abgrenzung, aktuelle Ergebnisse und Reformvorschläge.

Physical and psychosocial aspects of intersexuality (disorders of sex development, DSD) are described here. Differences between intersexuality and transsexuality are elaborated upon, especially in terms of coping with the diagnosis and treatment recommendations when dealing with an "ambiguous" or "false" body and with the disclosure of the physical conditions. The results of the Hamburg evaluation study, which was carried out between 2002 and 2008 on intersex adults, are summarized. These results have formed the basis of the comprehensive interdisciplinary book Intersexualität kontrovers (Controversial Intersexuality ) published in 2012. An outline of the recommendations published in February 2012 by the German National Ethics Committee (Deutscher Ethikrat) on Intersexuality is also provided. Finally, the "dangers" of sex reassignment and gender change are questioned and an opening up of the binary view of sex and gender is proposed.

Living with Kallmann Syndrome - Analysis of Subjective Experience Reports from Women.

Five women were questioned on their experiences with Kallmann Syndrome (KS) in thematically focused, open interviews. This investigation complements the study of the experiences of men with KS 1. The results show that the consequences and pressures of KS extend beyond the somato-medical field and that those affected are also burdened by mental and psycho-social impacts. The pressures experienced by those affected include a distorted body image resulting from the lack of physical development, which in turn leads to difficulties in developing a healthy feeling of self-worth. Furthermore, particular attention should be paid to the influence of hormone therapy on mood and libido during medical treatment. Some of the affected women reported experiencing depressive moods and low libido, and pressures in their relationship associated with this. The affected women wanted KS to be viewed as a whole in order to achieve better handling. In particular, attentive handling of issues relating to fertility was important to them. Additional relevant support included offers of confidential discussions, and offers of psychotherapy and, where required, sex education or sex therapy.

A European network for the investigation of gender incongruence: the ENIGI initiative.

Studies on diagnostic subtypes of gender identity disorder (GID) or gender incongruence (GI), comorbidity and treatment outcome show considerable variability in results. Clinic/country specific factors may account for the contradictory results, but these factors have never been studied. This article is the first of a series reporting on a unique collaborative study of four European gender identity clinics (the European network for the investigation of gender incongruence [ENIGI]). Here, we present the diagnostic procedures of the four clinics (Amsterdam, Ghent, Hamburg, and Oslo), the standard battery of instruments, and the first results regarding applicants with GI who seek treatment. Applicants in the four clinics did not differ in living situation, employment status, sexual orientation, and age of onset of GI feelings. However, the Amsterdam and Ghent clinic were visited by a majority of natal males, whereas Hamburg and Oslo see more natal females. Male applicants were older than female applicants within each country, but female applicants in one country were sometimes older than male applicants in another country. Also, educational level differed between applicants of the four clinics. These data indicate that certain sociodemographic and/or cultural characteristics of applicants have to be taken into account in future studies.

How do Individuals with Complete Androgen Insensitivity Syndrome, Mayer-Rokitansky-Küster-Hauser Syndrome or Polycystic Ovary Syndrome Experience Contact to Other Affected Persons?

Persons with different sex characteristics may suffer from a feeling of being "different" or "not normal". In this study, persons with one of 3 diagnoses (complete androgen insensitivity syndrome [CAIS]; Mayer-Rokitansky-Küster-Hauser syndrome [MRKHS], polycystic ovary syndrome [PCOS]) were asked whether they had contact to other affected persons and how they assessed this contact. The correlation between contact and psychological distress was evaluated. Material and Methods: Information on contacts to other affected individuals was obtained using a written questionnaire. Psychological distress was measured using the German version of the BSI (Brief Symptom Inventory). Results: Data from 11 individuals with CAIS, 49 women with MRKHS and 55 women with PCOS was analysed. The frequency of contacts to other affected individuals differed between the different diagnostic groups (with the highest frequency reported for the group with CAIS, and the lowest for the group with PCOS). Overall, the majority of individuals considered such contacts beneficial (CAIS 81.8 %; MRKHS 90 %; PCOS 83.3 %). The frequency of contacts and their assessment were not found to be correlated with psychological distress. The three diagnostic groups differed in the proportion of people who indicated a wish for contact with other affected persons. The desire to have contact with other affected persons was most commonly expressed by women with PCOS and high levels of psychological distress (60.9 %). Conclusion: Persons with different sex characteristics can benefit from contact to other affected individuals. Particularly women with PCOS and increased levels of psychological distress may benefit if the issue of support groups is addressed during treatment.

[Knowledge and expectations of young women concerning menopause: results of an empirical study]. / Wissen und Erwartungen junger Frauen zum Klimakterium. Ergebnisse einer empirischen Studie.

The primary objective of this survey was to obtain information about the knowledge and expectations young women have towards menopause. The second goal was to examine circumstances which might have an influence on those expectations, focussing on the impact of menopause on the mothers. 173 women aged 25 to 35 made up this non-clinical sample and filled in a questionnaire which was composed by the authors. The results show that young women have a fragmentary knowledge but hardly show any deeper understanding of the physiological or psychosomatic changes concomitant to menopause. The general expectation concerning menopause was more positive than described. The young women showed a slightly increased willingness to reorder their life and to overcome menopause on their own. In addition, they had a rather critical opinion towards medical help and especially towards hormonal replacement therapy. They also seem to have an opinion about menopause which is almost free from traditional taboos. Among factors that might influence those expectations, it was found that the estimation of the mother's menopause is important for the daughter's expectations. The more a mother's menopause was viewed as difficult, the more negative the expectations towards their own menopause were. No correlations were found between knowledge about menopause and the expectations concerning menopause. Neither different menstrual experiences not the experiences of gynaecological diseases reveal any influence on young women's expectations concerning their menopause.

[Childhood sexual abuse in the history of patients in high-frequency psychoanalytic long-term therapy--prevalence and diagnosis]. / Sexuelle Missbrauchserfahrungen in der Vorgeschichte von Patienten in hochfrequenten psychoanalytischen Langzeitbehandlungen. Prävalenz und Diagnosestellung.

276 treatment records of patients who were undergoing high-frequent, outpatient, individual, psychoanalytic therapy were analysed with respect to the prevalence and patterns of childhood sexual abuse in the history of these patients. 22.8% of all patients experienced narrowly defined sexual abuse during childhood (the end of the 17th year); additionally, 35.2% of all patients reported minor forms of sexually abusive experiences. The gender distribution, the age at onset of sexual abuse, and the relationship to the perpetrator were analysed. Looking at psychoanalytic diagnoses, a significant correlation between a history of childhood sexual abuse and a diagnosis of hysterical neurosis was found.

[Partnership relations of parents and parent-child relations of physical abuse and sexual abuse experiences in childhood from the viewpoint of young adults. Further results of the Hamburg Study (II)]. / Die Partnerbeziehung der Eltern und die Eltern-Kind-Beziehung bei körperlichen Misshandlungen und sexuellen Missbrauchserfahrungen in der Kindheit aus der Sicht junger Erwachsener. Weitere Ergebnisse der Hamburger Studie (Teil II).

616 women and 452 men responded to the extensive questionnaire on body and sexual experiences in childhood of the Hamburg Study. 23% of the women and 4% of the men have been classified as sexually abused, 28% of the women and 14% of the men as physically maltreated. Beside testing group differences, the main purpose of this study was to test, which variables would predict sexual abuse and physical maltreatment in multivariate analysis. In the first part of the study, the relevance of socioeconomic and family factors for the prediction of sexual abuse and physical maltreatment have been presented. In this part, the relevance of the relationship between the parents and of the parent-child relationship are discussed. Multivariate analysis demonstrate the importance to differentiate between the early childhood and the time of elementary school. Especially in the group of sexually abused and physically maltreated children we found a deterioration of the socioeconomic circumstances over time as well as of the quality of the relationship between the parents, both of whom may be related to each other. With regard to the parent-child relationship, the Parental Bonding Instrument (Parker 1975) and questions to rewards and punishments were presented. Especially in the groups of sexually abused children, lack of demarcation and intense control were univariate significant. Lack of welfare has been of importance in the multivariate models for the prediction of physical maltreatment. Rewards and appreciations were rare in the groups of physically maltreated children but especially frequent in sexually abused children. The importance of further research on specific problems of sexual abuse and physical maltreatment is discussed.

[Social and familial aspects in physical abuse and sexual abuse experiences in childhood from the viewpoint of young adults. Selected results of the Hamburg Study (1)]. / Soziale und familiäre Gegebenheiten bei körperlichen Misshandlungen und sexuellen Missbrauchserfahrungen in der Kindheit aus der Sicht junger Erwachsener. Ausgewählte Ergebnisse der Hamburger Studie (Teil 1).

The basic assumption of this investigation is that sexual abuse and physical maltreatment should not be investigated in isolation. Young adults have been asked to participate in a study on body and sexual experiences in childhood. It was tested how sexually abused and/or physically maltreated women and men differentiate from those without this experiences. 23% out of 616 women were classified as sexually abused and 28% as physically maltreated. 4% of the 452 men were allocated as sexually abused and 14% as physical maltreated. Aside from assessing group differences, the main purpose of this study was to test which variables would predict sexual abuse and physical maltreatment in multivariate analysis. In this part of the study, the relevance of socioeconomic and family factors for the statistical prediction of sexual abuse and physical maltreatment in multivariate analysis are presented.