What is a sexual development problem? It is a questionable genital image. The definitions of "Hermaphrodite", "Dual Sex" and "Intersex" used in the past do not fully reflect the truth. Because most of these patients are not actually "hermaphrodite". It just differs to different degrees in gender for some reasons. It occurs in one in 2000 children.
What are the causes? Genetics, some medications used during pregnancy, deficiency or excess of some hormones secreted after birth and during adolescence cause developmental problems in the genital organs.
What problems do they cause? Important problems such as sexual identity and sexual function problems, thoughts of inadequacy regarding sexuality, differences in sexual orientation, postponing intimacy with the opposite sex and avoiding marriage may arise. It can cause social adaptation and psychological problems, depression, insecurity, feeling lonely, self-confidence and behavioral problems, rebellion and rejection of family or treatment, self-harm and suicide. Realizing that you are not the gender you feel like is can have traumatic consequences. Long-term condition of external genitals; There are many concerns about the size of the penis in boys, amenorrhea in girls, lack of breast development and uterus, hormone treatments applied for years, and whether there will be a chance of fertility. In addition, 'gender dissatisfaction' may occur at an advanced age, which is determined at a varying rate (5-50%) depending on the type of sexual development problem.
There may be a boy who looks like a girl, a girl who looks like a boy. Girl-type sexual development problem is the most common. is the problem seen. Although the genetics and internal genital organ development of children in this group are girls, their external genitalia are like boys. The problem of male pattern sexual development is exactly the opposite. In other words, although the genetics and internal organ development are male, the external genital appearance is like a girl. Additionally, there may be a problem of sexual differentiation due to sex chromosome disorder or true bisexuality.
How is it noticed? How is it diagnosed? When should families be suspicious? It is an important symptom that the baby's external genitalia appearance is suspicious. Families' baby; should not forget,
• A "sexual development problem" should be suspected in cases such as a large clitoris in the child who is considered a girl, inguinal hernias on both sides and eggs being found on examination.
What symptoms should be paid attention to? Gender problems can be detected early with a detailed examination in infancy. A detailed genital examination must be performed in babies. Thus, early diagnosis can be made in the neonatal period. The chromosome structure and gonads (ovaries/testes) of babies with questionable external genitalia should be examined. In order to avoid any delay in diagnosis, "genital area examination" should be performed in detail and meticulously in all children who go to the doctor for any disease.
Lack of menstruation or breast development during adolescence is an important symptom. In some people, the external genitalia structure is not suspicious in infancy. Early diagnosis may not be possible. In adolescence, their differences with their peers become evident. In this period, amenorrhea, lack of breast development, and small penis size are important symptoms.
Not being able to have children in adulthood is an important symptom. The person may have a female gender under his male appearance, or he may have a male gender even though he is seen as a girl from the outside. . As a result of research conducted due to the inability to have children after marriage, sexual development problems may also occur in adulthood.
When is the gender decision made? Gender-related behavioral symptoms in children are more evident between the ages of 2-6. In order to avoid significant concerns and confusion, the gender of the child should be decided definitively before this age period, which is the time to get to know the sexual organs and gain the sexual identity.
What are the factors that play a role in the development of sexual identity? The child exhibits more behaviors appropriate to that gender, depending on how he/she identifies himself/herself. In other words, the gender one is raised in is more important in the development of sexual identity. In the first 1-2 years of age, the appropriate gender should be determined and the child should be raised in that direction. In addition, genetic structure and hormones also play an important role in sexual development. However, gender; It may not be compatible with the chromosome structure and sexual organs.
How should the gender decision be made? Multidisciplinary approach Children with sexual development problems must be examined, treated and followed up by the Gender Research Commission. This commission is a multidisciplinary board that may consist of many physicians, especially pediatric surgery and pediatric urology specialists, pediatric endocrinologists and child psychiatrists. This commission makes a recommendation to the family, taking into account the patients' future sexual life, psychology, expectations, fertility, social environment, and the chance of success of the surgical correction.
The family and the child should also be included in the gender decision; Anxiety and expectations should be taken into account. In determining gender, close communication with the family and the child who has reached the age of understanding and perception is necessary. The family and the child should participate in the gender decision-making process, and their concerns and expectations should be taken into account.
When should it be treated? The type and timing of treatment depends entirely on the age at diagnosis. Therefore, it is very important to determine the gender as soon as possible. In children with a definitive diagnosis and gender decision, the appearance of the external genitalia should be corrected by surgery within the first 2 years of age, in accordance with the gender they will be raised. However, in patients whose future status is uncertain and hesitant about their exact sexual identity, surgical treatments should be postponed to later ages and the patient should be allowed to determine his own future. In addition, irreversible surgical procedures should not be performed, considering possible gender unhappiness and gender reassignment requests in the future.
What types of surgeries are performed? In children whose gender is determined to be male, defective female internal genital organ remnants are removed. The small and malformed sexual organ is corrected into the shape of a penis. An egg bag is created just under the penis and the testicle, if any, is placed in this bag. If there is no testicle, a prosthesis is placed in the bag. In children whose gender is decided to be a girl, the genital organ that has grown into a penis is corrected into a clitoris. The vagina, which opens into the urinary tube, is separated from here and mouthed outside to the genital area. Genital lips are made from the foreskin. If there is no real vagina, an artificial vagina is created from tissues such as skin or intestines.
The experience of the surgeon is very important for the future sexual life, fertility and serious psychosis of these children. Due to social problems, surgery should be performed by specialists who have received the necessary training and experience in this regard.
Is surgical treatment sufficient? Are other treatments required? It is not enough to just create anatomical organs. Hormonal and psychological treatments that will last for many years are as important as correct surgical treatment. At every stage of diagnosis, follow-up and treatment of these patients, we must work together with a multidisciplinary approach and provide lifelong support.
How should these children be approached? How to behave? The physician, family and the environment have a great responsibility. Judging children can lead to suicide. These children have the potential to become functional individuals in society. This situation is not shameful, but the child's privacy must be respected. Serious problems such as feeling like a "creature" may occur as a result of frequent genital examinations, taking photographs, and negative attitudes. Adults with sexual development problems are not caused by diagnosis; In fact, they experience suicidal tendencies due to the behavior and perception of the family, doctor and society.
Basic points to consider:
• Gender determination is the earliest and shortest possible time. It should be done in a timely manner.
• Naming and registration should be postponed until after gender determination.
• There should be consistency in upbringing appropriate to the assigned gender.
• Gender roles (toys, games, friends and interests) should be left free.
• The child should be instilled with the feeling that he/she will make the decisions regarding his/her body.
• The child should not be offended during the examination, genital examination should be performed with permission.
>• Informing the child should be done gradually according to age and development level.
• Psychosocial support should continue until adulthood.
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