Hermaphroditism and hermaphrodites

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

Hermaphroditism is caused by congenital anomalies of both the gonad and the external genitalia of a person and is formed in the period until the eighteenth week of embryo development.

[1], [2], [3], [4]

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 is currently no official geographical statistics of this disease. Patients suffering from true or false hermaphroditism are examined and treated in family planning and reproduction centers, gynecological and urological hospitals and are "hiding" under the diagnoses "adrenogenital syndrome", "testicular feminization", "gonadal dysgenesis," ovotestis, "scrotal - anterior hypospadias with inguinal or "abdominal cryptorchidism".

Moreover, patients with hermaphroditism are often treated in psychiatric clinics, since the symptoms of true and false hermaphroditism in the form of transsexualism, homosexuality and bisexualism (intermittent 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 acquires special relevance in modern society.

[5], [6], [7],

Forms

[8], [9], [10]

False male hermaphroditism

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

False male hermaphroditism is a condition in which a man has an anomaly of the external genitalia. Male genital organs are similar to the external genitalia of a woman. These anomalies have long been known and well studied, since there are one in 300-400 newborn boys. Usually this is a combination of two anomalies. One of them is the abnormal development of the male urethra, and the other is an incorrect placement of the testicles.

The testicles lay in the embryo 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 can 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: the abdominal and inguinal. With this abnormality the scrotum is empty or there is complete aplasia.

Another anomaly with false male hermaphroditism is hypospadias. It represents underdevelopment of the peripheral parts of the male urethra with replacement of the missing part of this canal with a dense scar scar and a deformation of the penis. There are several forms of this anomaly, depending on the location of the external opening of the urethra.

[11], [12], [13], [14], [15]

Hypodecia of the glans penis

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

The stem form of hypospadias consists in the fact that the external opening of the urethra opens on the posterior surface of the trunk of the penis. From this opening to the head of the penis there is a short scar strand that pulls the head to the external opening of the urethra and thereby bends the penis in the form of a hook. This form of the disease causes trouble for the sick. The child sprays a stream of urine during urination. In adults, sexual intercourse is not possible because a curved and fixed downward penis can not be inserted into the vagina.

Scrotal-scrotal form of hypospadias

The external opening of the urethra opens at the root of the penis, where the scrotum begins. Mark the hypoplasia of the penis, as well as it is crocheted. Act of urination is carried out on a female type, squatting. Sexual intercourse is impossible.

Scrotal hypospadias

With this anomaly, the scrotum is split into two halves that look like large labia in women. The external opening of the urethra opens between the half of the split scrotum. The penis is underdeveloped and looks like a female clitoris. Act of urination according to female type.

Perineal hypospadias

The urethra is short, like a woman's, and it 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 observed, that is, the testes are either in the abdominal cavity or in the inguinal canals.

Newborn boys suffering from scrotal and perineal hypospadias are often recorded in maternity hospitals as girls. At such girl, external genitals look on female type. There are labia (a split scrotum), there is a clitoris (a poorly developed and twisted penis). Often such patients retain the so-called urogenital sinus. This is the cavity into which the urethra empties into the embryo (in the period of embryonic development) and the vagina opens. The opening of this urogenital sinus looks like an entry into the vagina. Sometimes such patients urinary sinus passes into the vagina vestigial rudiment. Such a girl urinates on a female type, squatting, and is brought up as a girl.

When puberty comes, there is a conflict between the biological and social sex.

Female pseudohermaphroditism

Female pseudohermaphroditism consists in the fact that a woman who has a female genetic (chromosomal) sex and a normal structure of internal genital organs (uterus with tubes and ovaries), the external genitalia resemble male genital organs. At birth, such patients are often mistakenly installed in the male passport office. 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) of the external genitalia in false female hermaphrodites.

• I degree - isolated clitoral enlargement.
• II degree - small labia is underdeveloped. There is a narrowing of the entrance to the vagina and an increase in the clitoris.
• III degree - an increase in the clitoris. Small labia absent. The large labia is underdeveloped. The urogenital sinus is preserved. The hole of the preserved genito-urinary sinus is located at the base of the enlarged clitoris.
• IV degree - the clitoris is large and similar to the hypospatic penis. He has a head and foreskin. At the base of this clitoris, the urogenital sinus opens, into which both the urethra and the vagina flow. Large labia become a split scrotum. Small labia absent. Thus, the external genital organs at the fourth degree of false female hermaphroditism look exactly like the external genitalia of the false male hermaphrodite, suffering from scrotal-perineal hypospadias. But the false female hermaphrodite has a uterus and ovaries, and the false male hermaphrodite has a prostate and testicles.
• V degree of masculinization of the external genital organs with false female hermaphroditism is expressed by the fact that there is a normally developed male penis with the male urethra. The vagina either opens at the root of the penis or opens into the back of the male urethra. The male urethra is formed from the urogenital sinus. This explains the fact that the vagina can open in the back of the urethra. The scrotum can be split, or maybe normally developed, but without testicles. The act of urination in these patients is performed standing, according to the male type. When V degree of false female hermaphroditism at birth is always mistakenly installed male gender, and patients fall into the field of vision of urologists.

Both female and male hermaphrodites have a "sexual member-clitoris", in which there are two cavernous bodies. This member is always bent downwards and becomes arched in the course of an erection due to cicatricial remnants of the underdeveloped urethra, which tighten the glans penis to the external opening of the urethra (in men) or to the urogenital sinus opening (in women).

Genitourinary 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 vagina vagina flow. Sometimes the depth of the genitourinary sinus reaches 10-14 cm. Thus, we emphasize once again that with false female and false male hermaphroditism, the external genital organs can look quite the same. Patients suffering from pseudohermaphroditism, it is necessary to do a surgical correction of the genital organs and change the legal sex if it was incorrectly determined at birth. False hermaphroditism is clinically manifested by homosexuality and transvestism.

[16], [17], [18], [19], [20], [21], [22], [23], [24], [25]

True hermaphroditism and true hermaphrodites

True hermaphroditism seems an amazing biological phenomenon. But all life on earth has gone from hermaphroditism. Viruses, bacteria and protozoa do not have sexes. Only one specimen is sufficient for reproduction. Not only primitive animal organisms exhibit hermaphroditism. It is also the norm for highly organized animals. For example, worms have a complete set of both female and male genital organs and for breeding enough one individual. 

Hermaphroditism is widespread among insects and flora. Hermaphroditism as a norm exists in fish, leeches, shrimp and even lizards. Since the person in the process of embryonic, intrauterine development repeats the whole process of the evolutionary development of the animal world on the planet "Earth" in about 1-2 months, people always had, is and will have hermaphroditism in various variants as an anomaly (ugliness).

True hermaphrodites are people who have gonads in both the male and female genders, and therefore there are sex hormones in the blood, both female and male. True hermaphroditism is an abnormality of the gonads, either in the form of separate male and female gonads, or in the form of ovoteistis.

It is necessary to distinguish two versions of true hermaphroditism.

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

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

In cases where the actual genitalia of the external genital organs are properly developed in the male or female type and the secondary sexual characteristics correspond to the structure of the external genital organs, the diagnosis of true hermaphroditism is possible only after puberty by the presence of two symptoms that are observed only with true hermaphroditism. This is transsexualism and bisexualism (intermittent sex). Transsexualism consists in the fact that a normally developed man considers himself to be a woman and appeals to doctors with a request to change his sex, he can not live in a male body. 

Or a normally developed woman (sometimes even having children) thinks that she is a man, and insists on legal and surgical sex change. As a rule, transsexualism develops gradually, in the sense that self-identification 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 a gonad opposite to the phenotypic status of a patient, a tumor (often adenoma) 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 guise of a man can have children, but then he has transvestism, then homosexuality and, in the end, he becomes a transsexual. Or a true hermaphrodite in the guise of a woman can also have children, but then she has transvestism, homosexuality and it comes to transsexualism. The second symptom that is observed only with true hermaphroditism is bisexualism or intermittent gender. A person at different periods of life has then male, then female sexual behavior. Sexual behavior depends on the prevalence of androgens or estrogens in the blood.

Thus, there is usually no clear distinction between transvestism, homosexuality, transsexualism and bisexualism, and all these four symptoms can be combined with true hermaphroditism. Currently, these sexual states are being treated with an effect on the brain, up to surgical operations on the brain. Effects on the brain can not cure the clinical symptoms of hermaphroditism. It is necessary to ensure that the brain with the blood received hormones of only one sex (male or female).

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

• true hermaphroditism in combination with anomalies of the external genitalia;
• true hermaphroditism without anomalies of the external genital organs and without secondary sexual signs of the contralateral sex.

True hermaphroditism in combination with anomalies of the external genital organs. Such anomalies are usually referred to as penoscrotal, scrotal or perineal hypospadias. Often, the preservation of the genitourinary sinus in combination with cryptorchidism is observed. Sometimes there are secondary sexual characteristics of sex, the opposite of passport. There is a sharp increase in the clitoris in the form of a hypo-sexual 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 floor, and hermaphroditism (true) is not diagnosed.

In true hermaphrodites who do not have any anomalies of the vulva and there are no inversions of secondary sexual characteristics, there is usually a complete set of all genital organs male or female, and there is a gonad or tissue of the gonad of the contralateral sex. In such patients, hermaphroditism is almost never diagnosed, although they have vivid symptoms of hermaphroditism in the form of transvestism, homosexuality, transsexualism and bisexualism. If such people turn to a urologist, andrologist, gynecologist or endocrinologist, these doctors ascertain the proper development of the external genital organs and send them to psychotherapy to the sexologist. Sexologists can neither diagnose nor cure hermaphroditism.

Transvestites, homosexuals and bisexuals usually resign themselves to their gender anomaly. And transsexuals are trying to change the legal sex by hook or by crook. The syndrome of transsexualism arises in such true hermaphrodites, who have a complete set of all genital organs of the same sex, which allows them to be the mother or the father of the child. But they have a gonada of the opposite sex. Transsexualism begins to increase as the hormone-forming tumor of the opposite sex originates in the gonad of the opposite sex in the form of an adenoma. And the radical treatment of transsexualism is to find and remove this gonad of the opposite sex with the tumor. There are three variants of gonad abnormalities with true hermaphroditism:

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

Sexologists believe that if the external genital organs (male or female) are developed normally and do not have any anomalies, then there can be no hermaphroditism. With true hermaphroditism, the external genital organs can be developed perfectly normally. True hermaphroditism is anomalies not of the external genital organs, but anomalies of the gonads.

There are three main morphological variants of true hermaphroditism:

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

Undoubtedly, there is another, fourth, morphological version of true hermaphroditism, when a person has complete sets of genital organs. Both men and women. Such hermaphrodites have a scrotum and testicles in the scrotum, there are epididymis, seminal ducts, seminal vesicles, prostate and penis with the male urethra. But the same person between the root of the penis and the beginning of the scrotum has an entrance to the vagina, the vagina, the cervix, the uterus, the fallopian tubes and the ovaries. The variant of such true hermaphroditism in a person in the domestic medical literature has not yet been described.

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

Much less often, hermaphroditism is observed in the mosaic structure of chromosomes: XX / XY; XX / XXYY; XX / XXY. Other variants of the set of sex chromosomes are also possible.

Based on clinical observations, a working classification of the 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.
  • Ovotiestis.
  • The mosaic structure of gonads.
• True hermaphroditism without anomalies of external genital organs
  • With male secondary sexual characteristics.
  • With female secondary sexual characteristics.
  • With secondary sexual characteristics of both sexes.
  • A complete set of genital organs of the same sex (male or female) gonad (or gonad tissue) of the opposite sex with a hormone-forming tumor in it, which is manifested by transsexualism.
• True hermaphroditism with the presence of anomalies of external podovyh bodies
  • A complete set of genital organs of the same 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 of the hermaphroditism

Sex is a very important characteristic of absolutely every person. In all documents that accompany a person from birth to death, the second line after the surname, name and patronymic is the designation of the sex. Sex is indicated on the birth certificate, in all questionnaires filled during the life and in the death certificate.

Diagnosis of sex in hermaphroditism is based on the definition of the six main sexual criteria. Therefore, sometimes they say and write about the fact that every person has not one, but six whole sexes, and they can coincide and do not coincide. Each person has a genetic floor, gonadal sex, hormonal sex, phenotypic sex, psychological (psychic) sex and legal (passport) sex.

The genetic floor is laid at the time of fertilization. It is also called chromosomal sex.

A normal chromosome set of a human contains 22 pairs of chromosomes. In addition, there are two more sex chromosomes. Total chromosomes in humans 46. Sex female chromosomes are designated by the sign X. There are two women in them. The chromosomal genotype of a woman 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 (spermatozoa) are formed in the male gonad (testicle), contain 22 autosomes and one sex chromosome (either the X chromosome or the Y chromosome). Y denotes the chromosome that defines the male gender. If, as a result of the fertilization of the ovum with sperm, a set of sex chromosomes XX is obtained, the female genital organs develop in the embryo. If you get a set of sex chromosomes XY, the embryo forms the male genital organs. So "conceived" by nature, but there are deviations. Male karyotype is designated 46XY. If, as a result of fertilization, the so-called mosaic set of sex chromosomes (XX / XY; XX / XXYY; XXX / XY; XX / XXY, etc.) results in the embryo forming both female and male genital organs, that is, a bisexual organism will develop false or true hermaphrodite. However, hermaphroditism can be formed even with a normal female karyotype (46XX) and with a normal male karyotype (46XY).

Diagnosis of chromosome, genetic sex, genotype, karyotype is carried out by studying chromosomes, but this requires special equipment and qualifications. A technique for diagnosing the genotype is widely used by the method of determining the sex chromatin of cell nuclei. To do this, perform a cut of the skin or scraping from the mucous membrane of the mouth, or a blood smear. The preparation is subjected to special staining. The location of the coloring parts in the nuclei of cells is different for men and women. The method for determining the genetic sex by sex chromatin is imperfect because the typical sex position for female sex occurs in women only in 70-90% of all cells, but this arrangement of sexual chromatin is found in 5-6% of the cells of the male body.

The chromosomal sex itself (in isolated form) is not an exact determinant of a person's sex. With a normal male genotype (46XY), a person can not be a woman, but he can turn out to be a hermaphrodite (bisexual) or eunuch (asexual). Thus, in the anorhism (gonadal agenesis) of aplasia of both testes, the karyotype can be masculine (46XY), the genitals develop either as a female type or have a rudimentary structure. This is classical eunuchoidism in the male genotype.

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

• female sex - the body has ovaries:
• male sex - there are eggs in the body;
• bipolarity (true hermaphroditism) - in the body there is both ovarian tissue and testicle tissue:
• (sexism) - in the body there are no sexual glands (gonads).

The gonad floor is determined by biopsy and histological examination. Pieces for histological examination are taken from both glands, since one of them may turn out to be an egg and the other an ovary. It is necessary to examine the gonad from one and the other poles, since one half of the gland can be the ovary, and the other - the testicle. This gonad is called ovotestis. The gland can also have a mosaic structure (in the ovary tissue there are parts of the testicle tissue, or, conversely, there are patches of ovarian tissue in the testicle tissue). In order to take a piece of the gonad for research, it must be found and uncovered. Gonads in humans are normally found in men in the scrotum, in women in the abdominal cavity at the sides of the uterus. With hermaphroditism, the testicle can be in the abdominal cavity and the ovary can be in the scrotum. By the way, the uterus may be in the scrotum. Gonads can also be in the large labia, in the inguinal canals, in the perineum and in the inguinal hernia. The sex glands in the scrotum, in the inguinal canals and in the labia are palpable. To determine the presence of gonads in the abdominal cavity, ultrasound and laparoscopy are performed, which can be combined with biopsy. Normally, the genetic floor should coincide with the gonadal sex, but they may not coincide, and then observe different variants of sex anomalies.

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

Diagnose the hormonal sex by determining the level of androgens and estrogens in the blood. Hormonal sex in humans is also four:

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

Normally, the genetic, gonadal and hormonal sex must coincide, that is, all of it must be masculine or all must be feminine. If they do not match, then there is an anomaly of the sex.

The fourth sex (sexual criterion) of each person is somatic or gender of the phenotype. This is the general appearance of a person, the structure of the external genitalia, secondary sexual characteristics, clothing and footwear, hair and jewelry. All these signs depend on the influence of sex hormones and can vary depending on the age and the appearance of tumors in the tissue of the gonads. Changes in the phenotypic pattern are always due to changes in the hormonal activity of the sexual glands. Phenotypic sex in man four:

• male sex - a man looks like a man;
• female sex - a person looks like a woman;
• two-fold in the appearance of man there are both male and female features;
• eunuchoidism - a person in appearance does not have either male or female features. He is childish and looks like a child.

The phenotypic sex always coincides with the gonadal and hormonal sex, but it may not coincide with the genetic sex. Phenotypic sex can be diagnosed only 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 with its diagnosis, errors are frequent, since the structure of the external genital organs may not correspond to the gonadal and hormonal sex. The somatic sex can change under the influence of hormonal treatment of certain diseases.

The fifth sex (sexual criterion) of a person is psychological or psychic. 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 there is no sexual behavior.

The psychological sex of children is determined by sexual psycho-orientation, which the child receives from parents and surrounding people. In sexually mature people, the psychological sex is determined by sexual autoidentification: how a person feels by a man or a woman. Mental sex four:

• male sex - male sexual behavior;
• female sex - female sexual behavior;
• the two-cavity manifests itself as male or female sexual behavior (alternating sex, bisexuality);
• sexlessness - there is no sexual behavior.

The sixth sex (sexual criterion) of a person is a legal, passport, metric, civil, social, legal sex. This is the floor, which is indicated in the personal documents of the person. There are only two legal sexes: male and female. The passport floor may not coincide with either the genetic floor, the gonadal sex, the hormonal floor, the somatic sex, or the psychological sex. Hermaphrodites and eunuchs have either male or female documents. In the first days after the birth of the child, the sex is officially registered male or female. In this case, the floor can be determined incorrectly. Incorrect sex determination takes place not only in cases of anomalies of the vulva. With typically female or male external genitalia, sex can be defined incorrectly, since a child may be a false or true hermaphrodite.

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

[26], [27]

Treatment of the hermaphroditism

In adults, the diagnosis, correction of sex and the treatment of hermaphroditism arise not only in the presence of anomalies of the external genitalia. Most often in adults, these issues occur with normally developed male or female genital organs. In such people, sex anomalies are manifested by clinical symptoms in the form of transvestism, homosexuality, transsexualism and bisexualism. In adults, the direction of correction or transformation of the sex is decided by the patient according to his sexual autoidentification. Sex change in adults should begin with hormone therapy, and then carry out surgical and legal sex change. The choice and sex change after puberty depends only on the desire to insist a sick person.

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

Correction of the external genital organs in the female side consists in surgical reduction in the size of the "clitoris penis", as well as in the creation of the vagina with the use of tissues and the urogenital sinus cavity, or alloplastic materials, or a fragment of the peritoneum. Moreover, now there are opportunities to create a surgical way of sexual gonads by transplantation into the body of a male or female gonad on a vascular pedicle, which will ensure the corresponding gonadal and hormonal sex. The hormonal floor can also be created by replanting the 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 bisexualism, but the prevention of these phenomena is completely dependent on pediatricians. They must understand the anomalies of the external genitalia and all such children should be referred to the urological, gynecological or pediatric surgical clinics.

True hermaphroditism can be cured if a gonad (or gonad tissue) of the opposite sex is found and removed in the body. You need to look for a gonad in the Douglas space, in the scrotum, in the inguinal canals and in the large labia. If a separate gonad is not found, a gonad biopsy should be done and in cases of ovotestis do a gonadal resection, and in cases of a mosaic gonad structure it is necessary to raise the issue of castration followed by hormone therapy or transplantation of the donor gonad and correction of the external genitalia. 

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

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

Prevention

Prevention of hermaphroditism is the minimization of the influence of factors that cause disembryogenesis, including the proper use of hormonal estrogen-containing contraceptive drugs by women planning pregnancy. It is proved that during conception of the fetus, which occurred against the background of prolonged hyperestrogenization of the female body, the risk of formation of anomalies of the external genital organs and sexual glands, in particular various forms of hypospadias in male fetuses, increases.

[28], [29], [30], [31], [32]

Forecast

The prognosis for the life of patients with hermaphroditism is generally favorable, but one must not forget about the possibility of malignancy of the abnormal gonad, including 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 scan of the gonadal tissue structure approximately once every six months. If neoplasm is detected, a biopsy and a histological study of the education must be performed to decide the need for a radical operation.

Unfortunately, at present, patients with false and true hermaphroditism, especially those who do not have external anomalies of the external genital organs, do not always get timely qualified help. This is due to two factors - insufficient illumination of this problem in the medical literature (the problem of hermaphroditism is not included in the curricula of medical universities), and the unwillingness of the patients themselves to advertise their condition, taking into account the specific clinical manifestations of this disease in the form of homosexuality, transsexualism, bisexualism and attitude towards them society.

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

[33], [34], [35]