Handbook of Clinical Gender Medicine. Группа авторов
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Название: Handbook of Clinical Gender Medicine

Автор: Группа авторов

Издательство: Ingram

Жанр: Зарубежная психология

Серия:

isbn: 9783805599306

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СКАЧАТЬ the corpus spongiosum, which normally surrounds the urethra, divides creating a ventral triangular defect whose summit is the division of the spongiosum; the lateral sides are the atretic pillars of spongiosum reaching the glans wings, and the open glans forms its base. All of the tissue in this triangle is poorly developed, leading to the ventral curvature of the penis and the poorly formed urethra. Most hypospadias classifications are wrongly based on only the position of the urethral meatus. The GT anomaly is far more complex and its severity must include the size of the GT, the glans, the length of the defective urethra, the quality of the tissues forming the urethral plate, and, moreover, the level of division of the corpus spongiosum. Accurate identification of GT development can only be established in the operating room, once the GT has been fully degloved. One can then distinguish hypospadias with a proximal division of the corpus spongiosum, which are associated with a ventral curvature, from those with a distal division of the corpus spongiosum, which have little or no curvature.

      Sexual Identities

      Understanding of and decision making for a child in the neonatal period with severely abnormal genitalia is an extraordinary challenge. It is quite paradoxical to opt for a gender without consulting the patient himself or herself. This process has been highly criticized by some patients and patient advocacy associations and remains quite controversial. To understand the complexity of these situations, one could distinguish three different identities. Individual sex identity, which is what the individual thinks he or she is, is quite a subtle spectrum and will be shaped by growth and external and internal influences. Behavioral identity, which is the individual’s erotic inclination, will also form with time. Both of these identities are invisible in the neonatal period. The last identity, i.e. social identity, (or gender) is how society looks at the individual and recognizes the individual as male or female. Social/gender identity is far more rigid, and less subtle, than the others. It is the way the social mirror reflects the individual’s image, i.e. the way to make the individual visible. It is the only tangible identity at birth.

      Decision Tools

      Hormonal Treatments

      Masculinization Surgery

      DSD surgery should be done by DSD surgeons, i.e. surgeons familiar with genital reconstruction in children. Hypospadias reconstruction is commonly performed between 6 months and 2 years of age and includes three main steps. The first step is full dissection of the GT to expose the level of division of the corpus spongiosum which is the proximal landmark of the GT anomaly. It is then possible to evaluate the quality of the tissues available and choose the most appropriate technique for urethroplasty. In the second step, the choice of urethroplasty is dependent upon the length of the urethra to reconstruct, the quality of the urethral plate, the size of the glans, and the availability of dorsal tissues. The third step consists of refashioning the ventral aspect of the GT by redistributing the tissues around the penis, with or without conservation of the foreskin. There is no universal technique for hypospadias repair and no gold standard technique. The outcome is dependent upon many factors, the most important of which is the experience of the surgical team and the quality of postoperative care.

      Feminization Surgery

      Feminization surgery is the ultimate alternative in patients carrying Y material. This surgery was common in the past in groups of patients with severe genital ambiguities for whom female assignment was the usual ‘by default’ response. The rationale was that it is surgically easier to create a penetrative conduit than a penetrating organ. Nowadays this option is much rarer even in mixed gonadal dysgenesis patients. The remaining indications are essentially СКАЧАТЬ