Degree Of Virilization Research Articles

Gender Role Across Development in Adults with 46,XY Disorders of Sex Development Including Perineoscrotal Hypospadias and Small Phallus Raised Male or Female

Self-rated degree of femininity and masculinity across development were evaluated for 40 adults affected by 46,XY disorders of sex development (DSDs) who presented at birth with a small phallus and perineoscrotal hypospadias, raised either male (n = 22) or female (n = 18). Most participants were confirmed or presumed to be affected by partial androgen insensitivity syndrome (n = 14), partial gonadal dysgenesis (n = 11), or were considered to have a poorly defined case of 46,XY DSD including ambiguous external genitalia (n = 15). Participants retrospectively evaluated their degree of masculinity and femininity during their childhood, adolescence, adulthood, and in the past 12 months of filling out a questionnaire pertaining to their psychosexual development. Participants raised male reported more masculinity than those raised female due to an increase in masculinization during adolescence and adulthood. Participants raised male also reported less femininity than those raised female throughout development. Participants raised female reported more femininity than those raised male due to an increase in feminization during adolescence and adulthood. Participants raised female also reported less masculinity than those raised male throughout development. These data support the proposition that some aspects of gender role (GR), such as masculinity and femininity, are capable of proceeding along female- or male-typic patterns depending on sex of rearing among individuals affected by specific types of 46,XY DSD. Furthermore, regardless of male or female rearing, GR increasingly corresponds with assigned sex as individuals proceed through sexual maturity and into adulthood. These results are consistent with the idea that socialization/learning contributes to GR development in humans in addition to data from others demonstrating endocrine influences.

A Man’s Brain in an Ambiguous Body: A Case of Mistaken Gender Identity

Chief complaint: “I feel like I have the brain of a man. Am I crazy?” On her first visit to a psychiatrist ( J.M.B.), “Ms. C,” a 48year-old woman, asked this question about her confused gender identity. Having also discovered a primary sexual attraction to women, Ms. C was having difficulty reconciling her church’s injunctions against sinful homosexual activities with her sense of herself as fundamentally male. She was dressed in a subtly frilly blouse and leather jacket she called “my leather-and-lace look.” Encircling each wrist were tattooed bracelets, traceries of curlicues and rosebuds that gently contradicted pearl earrings and a delicate gold locket. Born in the early 1950s and raised resolutely as a girl, Ms. C did not learn until she was 23 and married the unusual circumstances of her birth. Her mother finally divulged that she had entered the world with strange-looking genitals—neither male nor female. Doctors told her parents it was best to remove the odd tissue, fashion what remained to look female, and raise her as if nothing unusual had happened. At 6 months, surgeons removed both external tissue and presumed intra-abdominal testicular tissue and fashioned labia around the vaginal entrance she had always had. In grade school, she was told her large abdominal scar resulted from herniorrhaphy. At 12, after starting daily estrogen pills to induce puberty, she developed breasts and feminine curves, although without menarche or an increase in height beyond 5 feet. Her mother said she could not have children but did not explain why. She recalls being a tomboy who preferred boys for playmates. Because of her small stature and feminine appearance, however, boys were not particularly comfortable hanging out with her. Then, as now, she identified with the way males think rather than a sense of being physically male. She dated boys in high school, had a sexual experience with a woman during college, and married a man with whom she enjoyed satisfying marital relations for nearly two decades until they experienced a menage a trois. Her husband fell in love with the other woman, and she kindled awareness of her greater attraction to women than men. The marriage ended, and she embarked upon two long-term lesbian relationships and a struggle with alcoholism. Ms. C found sobriety and her church while that second relationship was unraveling. Welcomed and spiritually nurtured by church members, she felt happy except for increasing discontent with her pastor’s insistence that homosexual desires were her “cross to bear” and her options were either heterosexual marriage or celibacy. On one hand, her personal theology concurred that homosexuality was against God’s plan. On the other, she struggled with identifying herself as either man or woman, a dilemma her pastor could not solve. Ms. C’s childhood medical records had been lost. The psychiatrist asked if she had been karyotyped, given her unusual birth. She did not know. When she was born, chromosome testing was not routinely available. Given medical advice to raise her unquestioningly as a girl, the issue had not resurfaced. The psychiatrist suggested the test, and when results revealed 45,X/ 46,XY chromosomes, 75% the latter, the fragments—the childhood operation, hormones, her short stature, “brain of a man”—fell into place. She immediately reported feeling “less of a freak” now that she had a name—“intersexual”—for her condition.

Expression of AMH in Female Fetal Intersex Gonads in the Bovine

Anti Müllerian Hormone, AMH, is believed to be the main agent in the freemartin syndrome. Supposing an active role of freemartin gonads in AMH secretion, in the present study, we aimed at investigating the presence and the localization of AMH producing cells either in fetal or in adult freemartin gonads. Our finding of positive AMH cells in a 26-week-old freemartin fetus indicates an active role of masculinized freemartin gonads in AMH secretion. However, the positive reaction, limited to few cells grouped in 'nests' in proximity to testis cord-like structures, supports a chimeric origin of such cells, migrated from the male co-twin. No adult freemartin, irrespective from the degree of masculinization, showed any AMH positive cell.

Prospective Evaluation of Feminizing Genitoplasty Using Partial Urogenital Sinus Mobilization for Congenital Adrenal Hyperplasia

We present our experience with partial urogenital sinus mobilization in girls with congenital adrenal hyperplasia, with particular attention to vaginal caliber, introitus position, urinary continence and genital appearance. We present data on a prospective evaluation of 24 girls with congenital adrenal hyperplasia who underwent feminizing genitoplasty using urogenital sinus mobilization with preservation of the pubourethral ligaments during a 4-year period. Urogenital sinus length determined by cystoscopy and degree of external genitalia virilization, defined according to Prader classification, were evaluated before reconstruction. At followup patients were examined while under sedation for evaluation of overall external genitalia cosmesis and calibration of the vagina. Urinary continence status and voiding efficiency were assessed clinically in toilet trained patients by voiding diary, and measurement of bladder capacity and post-void residual by ultrasound. Patient age at operation ranged from 1 to 16 years (median 28.5 months), with a mean followup of 25 months (8 to 47). Degree of virilization was Prader type III in 3 children (12.5%), type IV in 16 (66.7%) and type V in 5 (20.8%). Urogenital sinus length was 2.5 cm or less in 17 children. Cosmetic results were good in 21 patients (87.5%) and satisfactory in 3 (12.5%). The vaginal and urethral openings were separate and identified at the surface of the vestibule in 21 girls. Adequate caliber of the mobilized vagina was achieved in 23 patients (95.8%). None of the 20 toilet trained children had urinary incontinence or recurrent urinary tract infections, with normal bladder emptying in 18 and small post-void residual in 2 (10%). Urinary continence and excellent cosmetic appearance with adequate exteriorization of the vaginal and urethral openings can be achieved in most children with urogenital sinus anomaly treated with partial urogenital sinus mobilization.

A New Classification for Genital Ambiguity and Urogenital Sinus Anomalies

The surgical management of children born with genital ambiguity and urogenital sinus anomalies is difficult and at times controversial. In attempting to describe the genitalia of such a patient, paediatric urologists have focused on the degree of masculinization, the length of the urogenital sinus, and the confluence of the reproductive tract and the urinary tract. Prader’s classification has been used to describe the degree of masculinization, and others have described the urogenital confluence as being either ‘high’ or ‘low’ [1,2].

Clinical and cytogenetic studies in intersex ewes

Nine Sarda x Lacaune ewes with intersexual characteristics and an infertility condition at the reproductive anamnesis were analysed. In order to make a diagnosis, we have evaluated their behaviour and performed clinical and laparoscopic examination of the reproductive tract, as well as cytogenetic analysis. The ewes showed basically a female phenotype but a clinical examination revealed a different degree of masculinization in the morphology of external genital organs. A shorter vagina was observed in female-like ewes and a hypertrophic clitoris in male-like ewes. Laparoscopic analysis evidenced the presence of testis in seven individuals and, for two of them, the gonadal position was subcutaneous. Different male characteristics in the nine subjects, were also observed in their behaviour with a different degree of masculinization. Their blood samples were used for determining the percentage of male cells on lymphocytes chromosome spreads by using the C-banding technique. The haematopoietic chimeras (XX/ XY) found in the lymphocytes confirmed the diagnosis of freemartinism for seven out of the nine subjects.

Face pigmentation and sex classification

Research into sex differences in faces has focused primarily on shape rather than pigmentation. What work has been done on pigmentation has focused on 1-D signals, such as overall hue (Tarr et. al. 2001) and albedo (e.g. Frost 1988). The current study sought to investigate whether there are other more complicated sex differences in pigmentation, and to determine whether these differences are actually used to perform sex classification. Two images, produced by averaging 22 male and 22 female Caucasian faces, were distorted such that the two average faces had the same androgynous shape. With the images spatially registered, we can determine where the average faces differ from one another in terms of luminance and hue. The male average is darker than the female average everywhere but the eyes and lips, which are equally dark across the sexes. Thus, there is greater contrast about the eyes and lips of the female than the male. A subsequent investigation of 36 male and 32 female Caucasian faces found these differences to be statistically significant. The same pattern of results was found with a comparable set of East Asian faces. For an experiment, faces were manipulated to increase or decrease the luminance contrast between the eyes, lips, and the rest of the face. Subjects were more likely to report a face as being male when the contrast between the eyes, lips, and the rest of the face was decreased, and more likely to decide a face was female when the contrast was increased. In another experiment, for female faces a significant, positive correlation was found between a measure of contrast and the rated femininity, while for male faces a significant, negative correlation was found between contrast and rated masculinity. Together, these findings provide evidence that there are spatially organized sex differences in face pigmentation, and that people use these differences to determine the sex and degree of masculinity or femininity of faces.

Male genital defect (Dumpton Syndrome) in the dog-whelk Nucella lapillus (Neogastropoda): Mendelian inheritance inferred, based on laboratory breeding experiments

Laboratory breeding of the dog-whelk, Nucella lapillus, has established that the male-sterilizing Dumpton Syndrome (DS)—underdevelopment, or non-development (aphally), of the penis, incomplete formation (non-closure) of the vas deferens, resulting in a split prostate—can be readily observed in male F1 progeny. Cultivated under high ambient concentrations of the antifouling agent tributyltin (TBT), DS-carrying females can be recognized by their lesser degree of masculinization (imposex): sterilization is thereby avoided. When Dumpton females are crossed, under high ambient TBT, with individuals from a non-DS-affected population (Bude, North Cornwall) DS is absent from both sexes. Crosses of these F1 progeny result in F2 progeny exhibiting the classic DS symptoms in both sexes. A Mendelian mechanism for DS inheritance is suggested by the data.

Gender assignment in female congenital adrenal hyperplasia: a difficult experience.

To report experience of gender (re)assignment in genotypic female (46XX) patients with congenital adrenal hyperplasia (f-CAH), a difficult and stressful experience if complicated with delayed presentation and inadvertent assignment. Between 1983 and 2002, 70 patients with f-CAH were counselled for gender assignment. The age at diagnosis and operation, the degree of virilization, parental consanguinity, the gender preference of the families, and the factors governing the decision-making process were determined. Forty-one (59%) patients presented after the neonatal period. All parents had already assumed or were advised of a gender for their children, based on the suggestive appearance of the external genitalia. Consequently, 49 patients were reared as female and 21 as "male". Only nine of these "males" could be reassigned as females (mean age at presentation 7.87 months, sd 10.42). Twelve children had to be reared as "male"(mean age at presentation 55.8 months, sd 32.42) in compliance with the parents' and the study group's decision, and appropriate masculinizing reconstructive surgery was undertaken. The difference in the mean age of those reassigned as female and those who remained "male" was significant (P < 0.001). The parental consanguinity rate among the families was especially high in the 'male' patients. CONCLUSIONS It is extremely difficult to correct the gender of patients with f-CAH when they present at >2.5 years old. Furthermore, the delay in diagnosis and the male bias in choice of gender in our population might be a result of strong social pressures on families, influenced by cultural, traditional and economic factors.

Disorders of androgen action.

Disorders of androgen action are the main cause of male pseudohermaphroditism and include 5alphaR deficiency and androgen receptor defects. 5alphaR deficiency is characterized by female genitalia with some degree of masculinization, clitoromegaly, and severely bifid scrotum corresponding to the so-called pseudovaginal perineoscrotal hypospadias. At the onset of puberty, increased muscle mass, development of pubic hair, and phallic growth are associated with the acquisition of male gender identity. Normal or increased levels of testosterone and an elevated testosterone-to-dihydrotestosterone ratio after human chorionic gonadotropin stimulation testing suggest 5alphareductase deficiency, and the diagnosis can be ascertained by identifying the mutation in the 5alphaR-2 gene. Whatever the patient's age at diagnosis, psychological evaluation with 5alphaRD is vital. Androgen receptor defects encompass two clinical expressions: the complete and partial androgen insensitivity syndromes. Complete androgen insensitivity syndrome should be suspected at birth in the presence of inguinal hernia in a girl without genital ambiguity. At puberty, the sign of alert is primary amenorrhea with normal female phenotype and harmonious mammary development but no pubic hair growth. Partial androgen insensitivity syndrome covers a wide spectrum of undervirilized phenotypes ranging from clitoromegaly at birth to infertile men. In all cases, complementary investigations should include plasma testosterone and luteinizing hormone as well as androgen-binding capacity in cultured genital skin fibroblasts. Diagnosis is confirmed by identification of the androgen receptor gene mutation. Although patients with complete androgen insensitivity syndrome are raised as females, patients with partial androgen insensitivity syndrome should be managed according to age at diagnosis, response to treatment with exogenous androgens, and the presence of an androgen gene mutation. Gonadectomy in complete androgen insensitivity syndrome should be performed before puberty, and androgen substitution may improve the development of external genitalia in some patients with partial androgen insensitivity syndrome. Psychological follow-up is necessary.

A review of the chemistry, biological action, and clinical applications of anabolic-androgenic steroids

Background: Since its discovery in 1935, numerous derivatives of testosterone have been synthesized, with the goals of prolonging its biological activity in vivo, producing orally active androgens, and developing products, commonly referred to as anabolic-androgenic steroids (AAS), that are more anabolic and less androgenic than the parent molecule. Objective: This article reviews the structure, biotransformation, and mechanism of action of testosterone and some of the most commonly used AAS. Clinical applications of the AAS are discussed, and guidelines and therapeutic maneuvers for minimizing their side effects are outlined. Methods: Literature for inclusion in this review was identified using the libraries of the University of Wisconsin Medical School and School of Pharmacy, the author's files, and searches of MEDLINE, Science Citation Index, Biological Abstracts, and Chemical Abstracts. Results: The myotrophic action of testosterone and its derivatives and their stimulatory effects on the brain have led to widespread use of AAS by athletes and “recreational” drug users. Consequently, all AAS were classified as class III controlled substances in 1991. Nonetheless, AAS have shown benefit in a variety of human disorders, including HIV-related muscle wasting and other catabolic conditions such as chronic obstructive pulmonary disease, severe burn injuries, and alcoholic hepatitis. Because of their diverse biological actions, AAS have been used to treat a variety of other conditions, including bone marrow failure syndromes, constitutional growth retardation in children, and hereditary angioedema. AAS therapy is associated with various side effects that are generally dose related; therefore, illicit use of megadoses of AAS for the purpose of bodybuilding and enhancement of athletic performances can lead to serious and irreversible organ damage. The most common side effects of AAS are some degree of masculinization in women and children, behavioral changes (eg, aggression), hepatotoxicity, and alteration of blood lipid levels and coagulation factors. Conclusions: To minimize or avoid serious toxicities with AAS therapy, close medical supervision and periodic monitoring are important, with dose adjustment as appropriate to achieve the minimum effective dose. Given the biological effects and potential adverse effects of AAS, administration of these agents should be avoided in pregnant women, women with breast cancer or hypercalcemia, men with carcinoma of the prostate or breast, and patients with nephrotic syndromes or significant liver dysfunction.

Propulsion: A behavioural expression of masculinity

Based upon studies of children's sex‐typed behaviours, it is theorized that a forceful, forward motor behaviour, or propulsion, is an integral component of several masculine sex‐typed behaviours. To test the relation between propulsion and masculinity, a game of tag was designed to elicit propulsion from 3‐ to 5‐year‐old children. In addition, in Study 1, teachers rated children's degree of masculinity and, in Study 2, the masculinity of children's toy preferences was assessed. Results showed a significant relation between propulsion and measures of masculinity. Findings are discussed in terms of the importance of considering motor behaviour in studies of sex typing.

The ovary retains male potential after the thermosensitive period for sex determination in the turtle Emys orbicularis

Emys orbicularis is a turtle with temperature-dependent sex determination. The thermosensitive period (TSP) lies between embryonic stages 16 and 22. Gonadal differentiation begins during this period involving oestrogens. Treatment with oestrogens during TSP results in the differentiation of ovaries at a male-producing temperature (25° C), whereas treatment with an antioestrogen (tamoxifen) or with nonsteroidal aromatase inhibitors results in gonadal masculinization at a female-producing temperature (30° C). The present study examines the effects on the ovary of inhibiting aromatase activity after TSP. Eggs of E. orbicularis incubated at 30° C were given five or seven applications of 10 μg aromatase inhibitor Letrozole (CGS 20267) in ethanol, between stages 22 + and 24–25 when ovarian aromatase activity strongly increases. Individuals which received five applications were sacrificed at stages 24 +–25. Those which received seven applications were sacrificed either at stage 25 + (close to hatching), or 34–36 days after hatching. Gonadal aromatase activity and related gonadal structure were studied in each individual. In the three series, the gonadal aromatase activity in individuals treated with Letrozole varied from similar or close to that in controls to much lower, and the gonadal structure varied from ovary-like to ovotestis. Ovotestes had the lowest levels of aromatase activity, under 4 fmoles/h/gonad, close to testis levels. They were found in 7 out of 26 individuals given Letrozole. Besides ovotestes, gonads presenting various degrees of masculinization, with enlarged epithelial cords and lacunae in the medulla, were found. Therefore, by inhibiting aromatase activity and thus estrogen synthesis, we were able to obtain the differentiation of testis-like cords or tubes in ovaries of E. orbicularis, after the period of temperature sensitivity. These results show that the ovary retains male potential after this period. Thus, besides their implication during the critical embryonic period for gonadal sex differentiation, oestrogens play a role in maintaining the ovarian structure after this period. A decrease in oestrogen levels could explain some other cases of ovarian masculinization known in vertebrates.

Corticosurrénalomes de l'enfant: analyse rétrospective de 54 cas

Background. — Adrenal tumors rarely occur in childhood. Their criteria for malignancy, as well as the effects of chemotherapy remains nearly defined. Population. — Fourty-five children (median age: 4 years) with an adrenal tumor diagnosed between 1973 and 1993 were included in this study. Results. — Seventy-six percent of the children showed various degrees of virilization. Tumor was palpable in 57%. Most patients (80%) had local disease. 7% loco-regional disease and 13% distant metastases. Forty-five children underwent an apparently complete surgical resection. Recurrence occurred 2 to 17 months after surgery in 18 of them (40%). Twenty-four children received medical treatment (o.p′-DDD or chemotherapy) and one-third had a tumoral response. The overall 5 year survita rate was 49%. Conclusions. — Adrenocortical neoplasms have a poor prognosis in childhood. Complete resection is the only effective and potentially curative treatment. Currently no effective chemotherapy exists, and the value of adjuvant therapy remains unproven. Multicentric studies are underway to evaluate the efficacy of therapeutic approaches.

Endocrine Sex Reversal of Gonads by the Aromatase Inhibitor Letrozole (CGS 20267) in Emys orbicularis, a Turtle with Temperature-Dependent Sex Determination

In embryos of Emys orbicularis, the sexual differentiation of gonads is influenced by the incubation temperature of eggs. Estrogens administered during the thermosensitive period result in the feminization of gonads at 25° (male-producing temperature), whereas an antiestrogen or aromatase inhibitors masculinize the gonads at 30° (female-producing temperature). The nonsteroid aromatase inhibitor Letrozole induces gonads with different degrees of masculinization, from ovary-like to testis-like. The present study examines the endocrine function of such masculinized gonads, at the end of embryonic life. Aromatase activity (which is involved in estrogen synthesis in ovary) and the status of Müllerian ducts (the regression of which reflects the secretion of a putative anti-Müllerian hormone by the Sertoli cells) were examined. One month after treatment with Letrozole, the gonads of embryos presented various levels of aromatase activity. There was a strong correlation among aromatase activity, gonadal structure, and Millerian duct status; high levels of aromatase (similar or close to those in control females) were found in ovary-like gonads; intermediate levels were found in gonads (masculinized ovaries or ovotestes?) exhibiting a cortex and a composite medulla containing a mixture of ovarian lacunae and testicular cord-like structures; low levels (similar or close to those in control males) were found in strongly masculinized gonads (testis-like or ovotestes). Müllerian ducts were regressing in the majority of embryos with gonads containing low levels of aromatase activity. In these individuals, gonads functioned as embryonic testes. These results confirm the implication of estrogens in gonadal differentiation. The origin of these hormones is controversial, so that the aromatase activity was compared in gonads, in the undissociated adrenal-mesonephric complex (AM), and in different parts of this complex during the thermosensitive period. At the female-producing temperature, the aromatase activity per unit of tissue increased in differentiating ovaries but it was low in AM and similar to that found in AM at male-producing temperature. In embryos whose gonads had been masculinized by early treatment with Letrozole, aromatase activity was unchanged in AM. These results suggest that the main source of estrogens involved in ovarian differentiation is the gonad itself.

Mixed Gonadal Dysgenesis

We describe clinical, cytogenetic, endocrine, and histopathological findings in 16 patients with mixed gonadal dysgenesis (MGD). All patients except 1 presented genital ambiguity and 10 of them had Ullrich-Turner manifestations. The 45,X/46,XY karyotype was the most frequent with a predominance of 45,X cells in both peripheral lymphocytes and gonads. In all cases Mullerian and Wolffian remnants and/or derivatives were found and in some patients both Wolffian- and Mullerian-derived structures were identified on the streak or testicular side. Postpubertal patients exhibited variable degrees of virilization and all of them had hypergonadotropism coexisting with low to normal baseline serum levels of testosterone; their testicular response to human chorionic gonadotropin (HCG) in terms of testosterone secretion was also variable, ranging from minimal to almost a normal response. All prepubertal patients but 1 had normal baseline levels of pituitary gonadotropins and testosterone and their gonadal response to the HCG challenge was highly variable. With the exception of 1 case, who had a 45,X/46,XY(p-) karyotype, no correlation between the cytogenetic data and degree of external genital ambiguity and the hormonal findings was observed. Additional information on the specific structural abnormalities involving the testis-determining gene of the Y chromosome in patients with MGD is needed in order to further understand the mechanisms responsible for the wide variability characteristic of this disorder.

Age and Gender Differences in Children's Halloween Costumes

Abstract Based on data reported by Serbin and Sprafkin (1986), we predicted that the Halloween costumes of first and second graders would be less gender stereotyped than those of preschoolers and children in kindergarten. Children from one public elementary school and two preschools (N = 178) were individually interviewed on Halloween. Children were asked which character they were, who they wanted to be next year, and their age. The resulting 113 different costumes were then rated by college students for degree of masculinity, femininity, and scariness. In addition to main effects of gender and grade, two of four predicted interactions were significant. Older boys tended to prefer less masculine and more feminine costumes than younger boys, and older girls tended to prefer more masculine and less feminine costumes than younger girls.

THE LANGUAGE OF FLOWERS.

People often use flowers to communicate messages, yet little published work sheds light on the variables related to choice of flowers and intended messages. Pilot work using the semantic differentials found relationships between desired message and flower color/mass. In a full study, approximately 600 adults were questioned with two surveys that asked respondents to indicate choices and rating (Likert scale) of three or four arrangements of the same flower type that varied only on the dimension of color. Based on initial selection, they then answered a series of questions measuring emotional characteristics conveyed by the flowers and which arrangements they would choose to convey different emotional messages. Different flower colors implied significantly different degrees of masculinity or femininity, formality, novelty, and perceived value. Blue-based flowers were the least attractive, would not be frequently used to convey emotional messages, and when selected, would primarily convey a romantic message. Results were not gender-dependent. This research has implications for flower breeders, growers, and retailers.

Male perceptions of female attractiveness: The effects of targets' personal attributes and subjects' degree of masculinity

This study examined the relationship between the degree of sexist beliefs held toward women by male subjects and their perceptions of attractiveness of females described as possessing either masculine or feminine personality characteristics. One hundred twenty-two undergraduate males were given the Macho Scale, the Auburn University Personal Behavior Summary, a biodata sheet, and were asked to judge previously rated photographs of women along a dimension of attractiveness. Results demonstrated that males perceived physically unattractive and average females described as affectionate and compassionate as more attractive than similarly rated females described as independent and assertive. High Macho subjects viewed females as less attractive than low Macho subjects. Physical attractiveness of the male subjects was largely unrelated to their ratings of the females.

Genitoplasty for intersex anomalies.

The child born with ambiguous genitalia requires prompt diagnosis, sex assignment and treatment. The incidence of intersex is approximately 1 in 30,000 newborns [7]. These patients are categorized based on the their gonadal presentation into female pseudo-hermaphrodites, male pseudohermaphrodites, true hermaphrodites and mixed gonadal dysgenesis [2, 6] (Table 1). The majority of these cases (60-70%) will be female pseudohermaphrodites secondary to the adrenogenital syndrome (types I-IV) (Table 2). Simply put, these patients suffer from a block in the normal production of cortisone which by negative feedback from the pituitary results in the continued stimulation and overproduction of the by products of steroid metabolism in the adrenal gland. High levels of androgenic steroids leads to various degrees of masculinization in the XX fetus with exclusively ovarian tissue for gonads. Variable degrees of phallic enlargement, fusion of the urethral folds to form a phallic urethra and proximal entry of the vagina into the urogenital sinus are the resulting effects. These babies may look like males with bilateral cryptorchidism and hypospadias. Secondary to an increase in ACTH production, these patients may also have hyperpigmentation of their skin over the external genitalia and nipples. Rarely, abnormal androgen stimulation in the fetus may come from the mother either from exogenous ingestion of androgen hormones or from maternal androgen secreting tumors [2, 6]. Excessive aldosterone production leads to salt wasting which is life threatening if not recognized and treated. Male pseudohermaphrodites encompass a wide group of patients with varying etiologies that may present as intersex patients in the newborn period or during hormonal changes associated with puberty. Together these patients all have exclusively testicular tissue with a 46,XY karyotype. The pathology in this group results from the inability of the testis to synthesis testosterone or the failure of target tissues to respond to circulating testosterone (androgen insensitivity). The decision to raise the child as a male centers around the potential for the phallus to function adequately in later sexual relations. Presently, attempts at phallic reconstruction have been disappointing [34, 35]. Because of this, in questionable cases, the tendency has been to choose a female sexual identity.