Hermaphroditism and hermaphrodites

Hermaphroditism in Greek means bisexuality. There are two types of hermaphroditism - true and false (pseudohermaphroditism).

Hermaphroditism is caused by congenital anomalies of both the gonads and the external genitalia of a person and is formed in the period up to the eighteenth week of embryonic development.

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Epidemiology

In the structure of gynecological and urological diseases, hermaphroditism occurs in 2-6% of cases. It is possible that the frequency of hermaphroditism is much higher. There are currently no official geographical statistics on this disease. Patients suffering from true or false hermaphroditism undergo examination and treatment in family planning and reproduction centers, gynecological and urological hospitals and "hide" under the diagnoses of "adrenogenital syndrome", "testicular feminization", "gonadal dysgenesis", "ovotestis", "scrotal-perineal hypospadias with inguinal or "abdominal cryptorchidism".

Moreover, patients suffering from hermaphroditism are often treated in psychiatric clinics, since the symptoms of true and false hermaphroditism in the form of transsexualism, homosexuality and bisexuality (alternating sex) are mistakenly considered diseases of the "sexual centers" of the brain. Therefore, the problem of diagnosis and treatment of true and false hermaphroditism is of a social nature and is especially relevant in modern society.

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Forms

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False male hermaphroditism

False hermaphroditism (pseudohermaphroditism) is a disease in which a person has gonads of one sex, but external genitalia, as a result of a developmental defect, resemble organs of the opposite sex. It is necessary to distinguish between male and female pseudohermaphroditism. A false male hermaphrodite is a man, but with female external genitalia and a female passport. A false female hermaphrodite is a woman, but with male external genitalia and a male passport.

False male hermaphroditism is a condition in which a man has abnormalities of the external genitalia. The external genitalia of a man are similar to the external genitalia of a woman. These abnormalities have long been known and well studied, as they occur in one in 300-400 newborn boys. Usually, it is a combination of two abnormalities. One of them is the abnormal development of the male urethra, and the other is the abnormal positioning of the testicles.

The embryo's testicles are laid in the lumbar region, and then descend, pass through the inguinal canals and descend into the scrotum. As a result of impaired embryogenesis, the testicles may remain in the abdominal cavity or in the inguinal canals and do not descend into the scrotum. This anomaly is called cryptorchidism. There are two forms of cryptorchidism: abdominal and inguinal. With this anomaly, the scrotum is empty or there is complete aplasia.

Another anomaly in false male hermaphroditism is hypospadias. It is an underdevelopment of the peripheral sections of the male urethra with the replacement of the missing section of this canal by a dense scar strand and deformation of the penis. Several forms of this anomaly are distinguished depending on the location of the external opening of the urethra.

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Hypospadias of the glans penis

The external opening of the urethra opens at the base of the head of the penis. This form of anomaly is not noticed by the patients themselves and they believe that in all people the external opening of the urethra is not at the pole of the head of the penis, but at the base. This form of anomaly does not interfere with either urination or sexual intercourse and does not require treatment.

The trunk form of hypospadias is that the external opening of the urethra opens on the back surface of the shaft of the penis. From this opening to the head of the penis there is a short scar strand, which pulls the head to the external opening of the urethra and thus curves the penis in the form of a hook. This form of the disease causes discomfort to patients. A child sprays urine when urinating. In adults, sexual intercourse is impossible because the curved and fixed downward penis cannot be inserted into the vagina.

Scrotal form of hypospadias

The external opening of the urethra opens at the root of the penis, where the scrotum begins. Hypoplasia of the penis is noted, and it is also curved into a hook. The act of urination is carried out in the female manner, while squatting. Sexual intercourse is impossible.

Scrotal hypospadias

In this anomaly, the scrotum is split into two halves, which look like the labia majora in women. The external opening of the urethra opens between the halves of the split scrotum. The penis is underdeveloped and looks like a female clitoris. The act of urination is of the female type.

Perineal hypospadias

The urethra is short, like a woman's, and opens on the perineum. The scrotum is split or absent. The penis is pulled up to the external opening of the urethra and looks like a clitoris. As a rule, with scrotal and perineal hypospadias, cryptorchidism is also observed, that is, the testicles are located either in the abdominal cavity or in the inguinal canals.

Newborn boys suffering from scrotal and perineal hypospadias are often registered in maternity hospitals as girls. Such a girl has external genitalia of the female type. There are labia (split scrotum), there is a clitoris (poorly developed and curved penis). Often, such patients retain the so-called urogenital sinus. This is the cavity into which the urethra flows in the embryo (during the period of embryonic development) and the vagina opens. The opening of this urogenital sinus looks like the entrance to the vagina. Sometimes in such patients, the urogenital sinus turns into a rudiment of the vagina. Such a girl urinates in a female pattern, squatting, and is raised as a girl.

When puberty occurs, a conflict arises between biological and social sex.

Female pseudohermaphroditism

Female pseudohermaphroditism is when a woman with female genetic (chromosomal) sex and normal structure of internal genitals (uterus with tubes and ovaries) has external genitals that resemble male genitals. At birth, such patients are often mistakenly assigned male passport sex. Upon reaching puberty, such a "man" behaves like a woman and becomes a passive homosexual.

There are five degrees of virilization (masculinization, i.e. male appearance) of the external genitalia in false female hermaphrodites.

• Grade I - isolated enlargement of the clitoris.
• II degree - the labia minora are underdeveloped. There is a narrowing of the entrance to the vagina and an enlargement of the clitoris.
• III degree - enlargement of the clitoris. The labia minora are absent. The labia majora are underdeveloped. The urogenital sinus is preserved. The opening of the preserved urogenital sinus is located at the base of the enlarged clitoris.
• IV degree - the clitoris is large and resembles a hypospadic penis. It has a glans and foreskin. At the base of such a clitoris, the urogenital sinus opens, into which both the urethra and the vagina flow. The labia majora take on the appearance of a split scrotum. The labia minora are absent. Thus, the external genitalia in IV degree of false female hermaphroditism look exactly the same as the external genitalia of a false male hermaphrodite suffering from scrotal-perineal hypospadias. However, a false female hermaphrodite has a uterus and ovaries, while a false male hermaphrodite has a prostate and testicles.
• The V degree of masculinization of the external genitalia in false female hermaphroditism is expressed by the presence of a normally developed male penis with a male urethra. The vagina either opens at the root of the penis or opens into the posterior section of the male urethra. The male urethra is formed from the urogenital sinus. This explains the fact that the vagina can open in the posterior section of the urethra. The scrotum can be split, or it can be normally developed, but without testicles. The act of urination in such patients is performed standing, according to the male type. In the V degree of false female hermaphroditism, the male sex is always mistakenly determined at birth, and patients come to the attention of urologists.

Both female and male hermaphrodites have a "clitoris penis" that contains two cavernous bodies. This penis is always curved downwards and, when erect, takes on an arched shape due to the cicatricial remnants of the underdeveloped urethra, which pull the head of the penis toward the external opening of the urethra (in men) or toward the opening of the urogenital sinus (in women).

The urogenital sinus in false and true hermaphrodites is a cavity that opens at the root of the clitoris or penis, into which the urethra and vagina or rudiment of the vagina flow. Sometimes the depth of the urogenital sinus reaches 10-14 cm. Thus, we emphasize once again that with false female and false male hermaphroditism, the external genitals can look absolutely identical. Patients suffering from pseudohermaphroditism must undergo surgical correction of the genitals and change their legal sex if it was determined incorrectly at birth. False hermaphroditism is clinically manifested by homosexuality and transvestism.

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True hermaphroditism and true hermaphrodites

True hermaphroditism seems like an amazing biological phenomenon. But all life on earth originated from hermaphroditism. Viruses, bacteria and protozoa have no sexes. One individual is enough for reproduction. Hermaphroditism is observed not only in primitive animal organisms. It is also the norm in highly organized animals. For example, worms have a full set of both female and male reproductive organs and one individual is enough for reproduction.

Hermaphroditism is widespread among insects and plants. Hermaphroditism as a norm exists in fish, leeches, shrimps and even lizards. Since a person in the process of embryonic, intrauterine development in about 1-2 months repeats the entire process of evolutionary development of the animal world on the planet "Earth", hermaphroditism in some form or another has always been, is and will be an anomaly (deformity) in humans.

True hermaphrodites are people who have both male and female gonads in their bodies, and therefore have both male and female sex hormones in their blood. True hermaphroditism is anomalies of the gonads, either in the form of separate male and female gonads, or in the form of ovotestes.

It is necessary to distinguish between two variants of true hermaphroditism.

• True hermaphrodites with anomalies of the external genitalia.
• True hermaphrodites without anomalies of the external genitalia.

If there are abnormalities in the development of the external genitalia, true hermaphroditism can be diagnosed in childhood. If there are no abnormalities in the external genitalia, true hermaphroditism can only be diagnosed after puberty. True hermaphrodites also often have clinical symptoms such as transvestism and homosexuality when the legal sex does not correspond to the hormonal sex, in cases where sex hormones opposite to the legal sex prevail in the blood.

In cases where true hermaphrodites have correctly developed external genitalia of the male or female type and secondary sexual characteristics correspond to the structure of the external genitalia, diagnostics of true hermaphroditism is possible only after puberty by the presence of two symptoms that are observed only in true hermaphroditism. These are transsexualism and bisexuality (alternating sex). Transsexualism is that a normally developed man considers himself a woman and asks doctors to change his sex; he cannot live in a male body.

Or a normally developed woman (sometimes even having children) considers herself a man, and insists on legal and surgical sex change. As a rule, transsexualism develops gradually, in the sense that the autoidentification of the sex opposite to the physical status of a person becomes deeper and deeper, and can even lead to suicide. This is explained by the fact that in the gonad opposite to the phenotypic status of the patient, a tumor (usually an adenoma) very often develops, which produces a huge amount of hormones of the sex opposite to the somatic status of this person.

Such a hermaphrodite in the form of a man can have children, but then he develops transvestism, then homosexuality, and, in the end, he becomes a transsexual. Or a true hermaphrodite in the form of a woman can also have children, but then she develops transvestism, homosexuality, and it comes to transsexualism. The second symptom, which is observed only in true hermaphroditism, is bisexuality or alternating sex. A person at different periods of life has either male or female sexual behavior. Sexual behavior depends on the predominance of androgens or estrogens in the blood.

Thus, there is usually no clear distinction between transvestism, homosexuality, transsexualism and bisexuality, and all four of these symptoms can be combined in true hermaphroditism. At present, these sexual conditions are being treated by influencing the brain, including brain surgery. Influencing the brain cannot cure the clinical symptoms of hermaphroditism. It is necessary to ensure that hormones of only one sex (male or female) enter the brain with the blood.

From a clinical point of view, true hermaphroditism can be divided into two categories:

• true hermaphroditism combined with anomalies of the external genitalia;
• true hermaphroditism without anomalies of the external genitalia and without secondary sexual characteristics of the contralateral sex.

True hermaphroditism combined with anomalies of the external genitalia. Such anomalies usually include penoscrotal, scrotal or perineal hypospadias. Often, the urogenital sinus is preserved in combination with cryptorchidism. Sometimes, secondary sexual characteristics of the sex opposite to the passport sex are present. The clitoris can be greatly enlarged in the form of a hypospadic penis.

Such people seek help from urologists, andrologists and gynecologists, and sometimes they are diagnosed with true hermaphroditism. But usually the external genitalia are surgically reconstructed and adjusted to the legal gender, and hermaphroditism (true) is not diagnosed.

True hermaphrodites, who have no abnormalities of the external genitalia and no inversions of secondary sexual characteristics, usually have a full set of all male or female genitalia, and a gonad or gonadal tissue of the contralateral sex. Hermaphroditism is almost never diagnosed in such patients, although they have clear symptoms of hermaphroditism in the form of transvestism, homosexuality, transsexualism, and bisexuality. If such people consult a urologist, andrologist, gynecologist, or endocrinologist, these doctors confirm the correct development of the external genitalia and send them to a sexologist for psychotherapy. Sexologists can neither diagnose nor cure hermaphroditism.

Transvestites, homosexuals and bisexuals usually come to terms with their gender anomaly. And transsexuals by hook or by crook achieve a change of legal gender. Transsexualism syndrome occurs in such true hermaphrodites who have a full set of all genitals of one sex, which allows them to be a mother or father of a child. But they have a gonad of the opposite sex. Transsexualism begins to increase as a hormone-producing tumor of the opposite sex in the form of an adenoma appears in the gonad of the opposite sex. And radical treatment of transsexualism consists in finding and removing this gonad of the opposite sex with the tumor. There are three variants of gonadal anomalies in true hermaphroditism:

• a person has one or two gonads, testicles, and he also has one or two ovaries;
• in humans, one or two gonads are constructed according to the ovotestis type;
• In humans, one or two gonads are constructed in a mosaic pattern. In the gonad, the tissues of the testicle and ovary are intertwined in a mosaic pattern.

Sexologists believe that if the external genitals (male or female) are developed normally and have no anomalies, then there can be no hermaphroditism. In true hermaphroditism, the external genitals can be developed absolutely normally. True hermaphroditism is not anomalies of the external genitals, but anomalies of the gonads.

There are three main morphological variants of true hermaphroditism:

• The first option: a person has a full set of genitals of one sex (male or female) and also one or two gonads of the opposite sex in the body without any anomalies of the external genitalia.
• The second option: a person has a full set of genitals of one sex (male or female), one or two gonads of the opposite sex, and other (except for the gonads) genitals of the opposite sex. In "men" (by full set of genitals) - a vagina or uterus, or mammary glands. In "women" (by full set of genitals) - a scrotum, penis, prostate.
• The third variant of true hermaphroditism: a person has gonads of both sexes and incomplete sets of other sexual organs in various combinations. This variant is characterized by various anomalies of the external genitalia and is therefore diagnosed most often by urologists, andrologists and gynecologists.

There is undoubtedly another, fourth, morphological variant of true hermaphroditism, when a person has a complete set of genitals. both male and female. Such hermaphrodites have a scrotum and testicles in the scrotum, there are epididymis, vas deferens, seminal vesicles, prostate and penis with male urethra. But this same person has an entrance to the vagina, vagina, cervix, uterus, fallopian tubes and ovaries between the root of the penis and the beginning of the scrotum. A variant of such true hermaphroditism in humans has not yet been described in Russian medical literature.

Hermaphroditism can develop against the background of any genetic, chromosomal sex. With a male chromosomal field of 46XY, hermaphroditism is most often accompanied by scrotal-perineal hypospadias with cryptorchidism, and the presence of a urogenital sinus, or without it. With a female chromosomal field of 46XX, hermaphroditism is most often observed in the presence of clitoral hypertrophy and vaginal ectopia of the urethra with or without the presence of a urogenital sinus.

Hermaphroditism is much less common with a mosaic chromosome structure: XX/XY; XX/XXYY; XX/XXY. Other variants of the sex chromosome set are also possible.

Based on clinical observations, a working classification of forms and variants of hermaphroditism has been developed.

Classification of forms and variants of hermaphroditism

• False hermaphroditism
  • Male false hermaphroditism.
  • Female false hermaphroditism.
• True hermaphroditism
  • Presence of gonads of both sexes.
  • Ovotestis.
  • Mosaic structure of the gonads.
• True hermaphroditism without anomalies of the external genitalia
  • With male secondary sexual characteristics.
  • With female secondary sexual characteristics.
  • With secondary sexual characteristics of both sexes.
  • A complete set of genital organs of one sex (male or female) and a gonad (or gonadal tissue) of the opposite sex with a hormone-producing tumor in it, which is manifested by transsexualism.
• True hermaphroditism with the presence of anomalies of the external reproductive organs
  • A complete set of genital organs of one sex (male or female) and the presence of organs of the opposite sex.
  • Incomplete sets of genital organs of both sexes in various combinations.
  • Complete sets of genital organs of both sexes, male and female.

Diagnostics hermaphroditism

Gender is a very important characteristic of absolutely every person. In all documents that accompany a person from birth to death, the second column after the last name, first name and patronymic is the gender. Gender is indicated on the birth certificate, on all questionnaires filled out during life and on the death certificate.

Gender diagnostics in hermaphroditism is based on the determination of six main gender criteria. That is why it is sometimes said and written that each person has not one, but as many as six genders, and they may or may not coincide. Each person has a genetic gender, gonadal gender, hormonal gender, phenotypic gender, psychological (mental) gender, and legal (passport) gender.

Genetic sex is determined at the moment of fertilization. It is also called chromosomal sex.

The normal human chromosome set contains 22 pairs of chromosomes. In addition, there are two sex chromosomes. A person has 46 chromosomes in total. Female sex chromosomes are designated by the X symbol. Women have two of them. The female chromosomal genotype is designated 46XX. Sex cells (gametes) contain a half set of chromosomes, which includes only one sex chromosome. Egg cells are formed in the female gonad (ovary) and contain 22 chromosomes (autosomes) and one sex X chromosome. Spermatozoa (spermin) are formed in the male gonad (testicle), contain 22 autosomes and one sex chromosome (either the X chromosome or the Y chromosome). Y is the designation of the chromosome that determines the male sex. If, as a result of fertilization of the egg by the sperm, the resultant set of sex chromosomes is XX, the embryo develops female genitalia. If the resulting set of sex chromosomes is XY, the embryo will develop male genitals. This is how nature "intended" it, but deviations occur. The male karyotype is designated 46XY. If fertilization results in a so-called mosaic set of sex chromosomes (XX/XY; XX/XXYY; XXX/XY; XX/XXY, etc.), then the embryo will develop both female and male genitals, i.e. a bisexual organism will develop in the form of a false or true hermaphrodite. However, hermaphroditism can develop with both a normal female karyotype (46XX) and a normal male karyotype (46XY).

Diagnostics of chromosomal, genetic sex, genotype, karyotype are carried out by studying chromosomes, but this requires special equipment and qualifications. A widespread method of diagnosing genotype is the method of determining the sex chromatin of cell nuclei. For this, a skin section or a scraping from the oral mucosa, or a blood smear is made. The preparation is subjected to special staining. The location of the stained parts in the cell nuclei is different in men and women. The method of determining genetic sex by sex chromatin is imperfect because the typical female sex location of sex chromatin is found in women only in 70-90% of all cells, while such location of sex chromatin is found in 5-6% of cells in the male body.

Chromosomal sex in itself (in isolation) is not an accurate determinant of a person's gender. With a normal male genotype (46XY), a person cannot be a woman, but he or she may be a hermaphrodite (bisexual) or a eunuch (asexual). Thus, with anorchism (gonadal agenesis) of aplasia of both testicles, the karyotype may be male (46XY), the genitals develop either according to the female type or have a rudimentary structure. This is classic eunuchoidism with a male genotype.

The second sex (sexual criterion) that every person has is gonadal. This sex is also called true sex or biological sex. There are four gonadal sexes in humans:

• female gender - the body has ovaries:
• male gender - there are testicles in the body;
• bisexuality (true hermaphroditism) - the body contains both ovarian tissue and testicular tissue:
• asexuality (eunuchoidism) - there are no sex glands (gonads) in the body.

Gonadal sex is determined by biopsy and histological examination. Pieces for histological examination are taken from both glands, since one of them may be a testicle, and the other an ovary. It is necessary to examine the gonad from one and the other pole, since one half of the gland may be an ovary, and the other a testicle. Such a gonad is called an ovotestis. The gland can also have a mosaic structure (there are areas of testicular tissue in the ovarian tissue, or, conversely, there are areas of ovarian tissue in the testicular tissue). In order to take a piece of the gonad for examination, it must be found and exposed. In humans, gonads are normally located in the scrotum in men, and in the abdominal cavity on the sides of the uterus in women. In hermaphroditism, the testicle may be in the abdominal cavity, and the ovary may be in the scrotum. By the way, the uterus may also be in the scrotum. Gonads can also be found in the labia majora, in the inguinal canals, in the perineum, and in inguinal hernias. The sex glands in the scrotum, in the inguinal canals, and in the labia can be palpated. To determine the presence of gonads in the abdominal cavity, ultrasound and laparoscopy are performed, which can be combined with a biopsy. Normally, the genetic sex should match the gonadal sex, but they may not match, and then different variants of sex anomalies are observed.

The third sex (sexual criterion) is hormonal. It is also called biological or true sex. It would seem that the gonadal sex should always coincide with the hormonal sex because sex hormones are produced by the gonads. The ovary always produces estrogens, and the testicle should always produce androgens.

Hormonal sex is diagnosed by determining the level of androgens and estrogens in the blood. There are also four hormonal sexes in humans:

• male - normal level of androgens in the blood;
• female - normal level of estrogen in the blood;
• hermaphroditism in the blood high levels of both androgens and estrogens (the amount of male and female sex hormones in the blood varies widely);
• asexuality - there are no or almost no female or male sex hormones in the blood.

Normally, genetic, gonadal and hormonal sexes should match, that is, all of them should be male or all of them should be female. If they do not match, then a sex anomaly occurs.

The fourth sex (sexual criterion) of each person is somatic or phenotype sex. This is the general appearance of a person, the structure of the external genitalia, secondary sexual characteristics, clothing and footwear, hairstyle and jewelry. All these characteristics depend on the influence of sex hormones and can change depending on age and the occurrence of tumors in the gonadal tissue. Changes in the phenotypic picture are always due to changes in the hormonal activity of the sex glands. There are four phenotypic sexes in humans:

• male gender - a person looks like a man;
• female - a person looks like a woman;
• bisexuality in the appearance of a person there are both male and female features;
• Eunuchoidism - a person has neither male nor female features in his external appearance. He is infantile and looks like a child.

Phenotypic sex always coincides with gonadal and hormonal sex, but may not coincide with genetic sex. Phenotypic sex can only be diagnosed in sexually mature people by their appearance. Children do not have secondary sexual characteristics, and somatic sex is diagnosed only by the structure of the external genitalia. And when diagnosing it, errors are common, since the structure of the external genitalia may not correspond to the gonadal and hormonal sex. Somatic sex can change under the influence of hormonal treatment of some diseases.

The fifth sex (sexual criterion) of a person is psychological or mental. This sex is completely determined by the presence or absence of sex hormones in the blood. Children do not have sex hormones in the blood and do not have sexual behavior.

The mental sex of children is determined by the sexual psychoorientation that the child receives from parents and people around him. In sexually mature people, the psychological sex is determined by sexual autoidentification: who a person feels like - a man or a woman. There are four mental sexes:

• male gender - male sexual behavior;
• female gender - female sexual behavior;
• bisexuality is manifested by alternately male and female sexual behavior (alternating sex; bisexuality);
• asexuality - there is no sexual behavior.

The sixth sex (sexual criterion) of a person is the legal, passport, metric, civil, social, legal sex. This is the sex that is indicated in a person's personal documents. There are only two legal sexes: male and female. The passport sex may not coincide with the genetic sex, nor with the gonadal sex, nor with the hormonal sex, nor with the somatic sex, nor with the psychological sex. Hermaphrodites and eunuchs have either male or female documents. In the first days after the birth of a child, the sex of a male or female is officially registered. In this case, the sex may be determined incorrectly. Incorrect determination of sex occurs not only in cases of anomalies of the external genitalia. With typically female or male external genitalia, the sex may be determined incorrectly, since the child may be a false or true hermaphrodite.

The complex of the above-described studies is a diagnostic algorithm for hermaphroditism. Only by determining all six sexual criteria, as well as carefully analyzing the patient's complaints and clinical symptoms, can the diagnosis and morphological form of hermaphroditism be established.

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Treatment hermaphroditism

In adults, the issues of diagnostics, gender correction and treatment of hermaphroditism arise not only in the presence of anomalies of the external genitalia. Most often, in adults, these issues arise with normally developed male or female genitalia. In such people, gender anomalies manifest themselves with clinical symptoms in the form of transvestism, homosexuality, transsexualism and bisexuality. In adults, the direction of gender correction or transformation is decided by the patient himself according to his sexual autoidentification. Gender reassignment in adults should begin with hormone therapy, and then undergo surgical and legal gender reassignment. The choice and change of gender after puberty depends only on the desire and insistence of the patient.

Thus, urologists and gynecologists can now, using surgical treatment of hermaphroditism, create male and female external genitalia. On the male side: by straightening the deformed body of the penis and creating an artificial male urethra from the patient's own tissues, as well as surgical or hormonal (using human chorionic gonadotropin) lowering of the testicles into the scrotum. The scrotum, in turn, is created from the skin of the perineum or "labia" of the patient.

Correction of the external genitalia to the female side consists of surgical reduction in the size of the "clitoris-penis", as well as the creation of a vagina using tissues and the cavity of the urogenital sinus, or alloplastic materials, or a fragment of the peritoneum. Moreover, now there are opportunities to create sex gonads surgically by transplanting a male or female gonad on a vascular pedicle into the body, which will ensure the appropriate gonadal and hormonal sex. Hormonal sex can also be created by implanting cultures of embryonic cells that produce sex hormones into the body. These methods relieve patients from the daily administration of synthetic sex hormones.

Children do not have clinical manifestations of true and false hermaphroditism in the form of transvestism, homosexuality, transsexualism and bisexuality, but the prevention of these phenomena depends entirely on pediatricians. They should understand the anomalies of the external genitalia and all such children should be referred to urological, gynecological or pediatric surgical clinics.

True hermaphroditism can be cured if a gonad (or gonadal tissue) of the opposite sex is found and removed from the body. The gonad should be looked for in the Douglas pouch, in the scrotum, in the inguinal canals, and in the labia majora. If a separate gonad is not found, a gonadal biopsy should be performed and, in cases of ovotestis, a gonadal resection should be performed, and in cases of mosaic gonadal structure, the question of castration with subsequent hormone therapy or donor gonad transplantation and correction of the external genitalia should be raised.

Treatment of hermaphroditism is very effective and consists of removing the gonads of one sex and leaving the gonads of the other sex. The direction of sex correction in the male or female direction depends on the development and anomalies of other genital organs, except for the gonads. Sexually mature patients usually choose the direction of sex correction themselves. They themselves feel either men or women. This sexual self-perception depends only on which sex hormones (male or female) prevail in the body.

Dynamic monitoring of patients with false and true hermaphroditism consists of periodic determination of the concentration of pituitary-gonadal hormones in the blood, and ultrasound examination of the genitals and gonads. It is necessary to control the stability of the patient's sexual autoidentification and his phenotypic secondary sexual characteristics.

Prevention

Prevention of hermaphroditism - minimization of the influence of factors causing dysembryogenesis, including the correct use of hormonal estrogen-containing contraceptives by women planning pregnancy. It has been proven that when a fetus is conceived against the background of long-term hyperestrogenization of the female body, the risk of developing anomalies of the external genitalia and sex glands increases, in particular various forms of hypospadias in male fetuses.

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Forecast

The prognosis for the life of patients with hermaphroditism is generally favorable, but one should not forget about the possibility of malignancy of the abnormal gonad, including the ovotestis. In this case, the prognosis of the disease depends on the histological form of the gonadal neoplasm. For the purpose of prevention and early warning of the disease, it is advisable to conduct an ultrasound examination of the structure of the gonadal tissue approximately once every six months. If a neoplasm is detected, it is imperative to perform a biopsy and histological examination of the formation to decide on the need for radical surgery.

Unfortunately, at present, patients with false and true hermaphroditism, especially those who do not have external anomalies of the external genitalia, do not always receive timely qualified assistance. This is due to two factors - insufficient coverage of this problem in medical literature (the problem of hermaphroditism is not included in the curricula of medical universities), and the reluctance of the patients themselves to advertise their condition, given the specific clinical manifestations of this disease in the form of homosexuality, transsexualism, bisexuality and the attitude of society towards them.

Therefore, most of these patients are in the category of sexual minorities. It sounds absurd, but patients with hermaphroditism, who have external anomalies of the external genitalia, are in a better position. They, as a rule, attract the attention of urologists or gynecologists, they undergo a special examination, as a result of which gonadal anomalies are often detected.

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