Estudio psicográfico de las características psicológicas de infantes y adolescentes con hiperplasia adrenal congénita y cirugía genital / Psychological characteristics of infants and adolescents with congenital adrenal hyperplasia and genital surgery: psychographic study

Introducción: La práctica de la cirugía genital es frecuente en infantes y adolescentes diagnosticados de intersexualidad. Una de sus principales consecuencias se refleja en la personalidad del paciente. Existen numerosos estudios en población adulta, pero son escasos en edades pediátricas. El dibujo constituye un instrumento valioso para la exploración psicológica en edades tempranas. Objetivo: Identificar las características psicológicas de infantes y adolescentes con tratamiento quirúrgico de los genitales, y de su desarrollo psicológico en el momento de la valoración. Métodos: Estudio transversal descriptivo y metodología cualitativa. La muestra la integraron 15 participantes entre 6 y 12 años, con hiperplasia adrenal congénita y cirugía genital. De ellos, 4 con asignación al sexo masculino y 11 con asignación femenina. Todos residentes en La Habana, Cuba y captados de las consultas de seguimiento de los servicios de Endocrinología del Instituto de Endocrinología y hospitales pediátricos. Se aplicaron las técnicas psicográficas (dibujo espontáneo, dibujo temático de la familia y dibujo temático "Así soy yo"). Resultados: El desarrollo psicológico se correspondió con la edad cronológica. El 100 por ciento presentó un pensamiento coherente y estructurado. El 50 por ciento presentó indicadores emocionales que aluden a insatisfacción con el propio yo, angustia (40 por ciento), y falta de aceptación del propio cuerpo (70 por ciento); además, expresaron dificultades en la comunicación familiar (60 por ciento). Conclusiones: Los indicadores globales relevantes de los dibujos denotaron daño emocional, dificultades en la aceptación, percepción y representación del esquema corporal y también en la comunicación social y familiar. Resulta impostergable intervenir en las causas del malestar y los problemas psicológicos de los sujetos estudiados para evitar que se desarrollen enfermedades psiquiátricas en la edad adulta(AU)

Introduction: The practice of genital surgery is frequent in infants and adolescents diagnosed with intersex. One of the main consequences is reflected in the patient´s personality. There are numerous studies in the adult population; however, they are rare in pediatric ages. Drawing is a valuable tool for psychological exploration in early ages. Objective: Identify the psychological characteristics of infants and adolescents with surgical treatment of the genitalia, and to characterize their psychological development. Method: Descriptive cross-sectional study and qualitative methodology. The sample was made up of 15 infants and adolescents between 6 and 12 years old with congenital adrenal hyperplasia and genital surgery. 4 of them with male sex assignment and 11 with female assignment, coming from the primary care level, residents in Havana, Cuba, recruited in the follow-up consultations of the endocrinology services of the Institute of Endocrinology and pediatric hospitals. The psychographic techniques (spontaneous drawing, thematic drawing of the family and thematic drawing called "I am like this" were applied). The study complied with the basic ethical aspects of scientific research. Results: Psychological development corresponded with chronological age. 100 percent of the patients presented a coherent and structured thinking. 50 percent presented emotional indicators that allude to dissatisfaction with one's own self, anguish (40 percent), and lack of acceptance of one's own body (70 percent); in addition, they expressed difficulties in family communication (60 percent). Conclusions: The relevant global indicators of the drawings denoted emotional damage, difficulties in the acceptance, perception and representation of the body scheme and also in social and family communication. It cannot be postponed an intervention in the discomfort causes and psychological problems of the patients studied, in order to avoid that psychiatric diseases can be developed in adults ages(AU)

Mosaicismo sexual / Sexual mosaicism

RESUMEN Los trastornos del desarrollo sexual son estados congénitos en los cuales el desarrollo del sexo cromosómico, gonadal o anatómico es atípico. Por tratarse de un caso sumamente raro consideramos de interés su presentación. Se presenta adolescente masculino de 15 años, con antecedentes de genitales atípicos al nacer, desarrollo de baja talla y estigmas turnerianos, pubertad espontánea y normal. Los estudios genéticos determinaron como sexo cromosómico un mosaico 45,X/46,XY/47XYY, y sexo molecular varón. Se inscribió socialmente como varón, se le realizó cirugía de reconstrucción genital y utilizó tratamiento con hormona de crecimiento biosintética que mantiene actualmente. La evolución clínica ha sido favorable con adecuada integración social. Ante la presencia de genitales atípicos al nacer se necesita de un manejo multidisciplinario. El diagnóstico etiológico de los trastornos de la diferenciación sexual requiere de una alta pericia médica. Un tratamiento integral en estos pacientes les garantiza una buena calidad de vida(AU)

ABSTRACT Sexual development´s disorders are congenital states in which the development of the chromosomal, anatomic or gonadal sex is atypical. Since this is a very rare case, we consider it as of interests for presentation. It is presented a teenager, 15-years-old male, with a history of atypical genitalia at birth, development of short height and Turner's stigmas, and spontaneous and normal puberty. The genetic studies identified as chromosomal sex a mosaic 45,X/46,XY/47XYY and male as molecular sex. He was socially registered as a male, he had a genital reconstruction surgery and he was under treatment with biosynthetic growth hormone that he currently maintains. The clinical evolution has been favourable with adequate social integration. In the presence of atypical genitalia at birth, it is needed a multidisciplinary management. The etiological diagnosis of disorders of sexual differentiation requires a high level of medical expertise. A comprehensive treatment in these patients guarantees them a good quality of life(AU)

Refinamentos estéticos na aparência da vulva na cirurgia de adequação genital / Esthetic refinements to the appearance of the vulva in sex reassignment surgery

Introdução: A cirurgia de adequação genital tem se mostrado uma opção segura e confiável, com redução drástica na disforia e melhora da qualidade de vida das pessoas transgênero. A técnica mais estudada e utilizada é a inversão peniana com suas modificações, com aparência estética e funcionalidade adequadas, porém sem padronização da técnica cirúrgica. Índices de até 38% de satisfação parcial e 15% de insatisfação podem levar até 66% dos casos a realizar procedimentos adicionais. O objetivo é sugerir refinamentos estéticos na aparência da vulva e comparar com algumas das técnicas descritas, buscando aumentar a satisfação estética e funcional pós-operatória. Métodos: Estudo retrospectivo com 7 pacientes submetidas à cirurgia de readequação sexual entre agosto de 2017 e fevereiro de 2018. O clitóris é feito com a glande em formato de tridente, utilizando a coroa para construir os corpos cavernosos do clitóris e aumentar a área de sensação erógena. Faixa de prepúcio é usada para aumentar a cobertura do clitóris e cobrir a face interna dos pequenos lábios, que são definidos com o uso de suturas. Resultados: Sensibilidade adequada e satisfação com o resultado e capacidade de orgasmo em todas as pacientes observadas. Não houve estenose, fístula ou necrose do clitóris com essa técnica. Somente 1 caso precisou de procedimento adicional para melhor definição estética. Conclusão: A técnica apresentada tem alta satisfação das pacientes e sensibilidade erógena, com algumas vantagens em relação a outras técnicas. Porém, estudos prospectivos com número maior de pacientes são necessários para definir a técnica cirúrgica mais efetiva.

Introduction: Sex reassignment surgery is a reliable and safe option, which has drastically reduced dysphoria and improved the quality of life of transgender individuals. The most studied and used technique is penile inversion with modifications, which results in appropriate esthetic appearance and functionality, but the surgical technique has not been standardized. Partial satisfaction rates up to 38% and dissatisfaction rates of 15% may cause up to 66% of cases to undergo additional procedures. The objective is to suggest esthetic refinements to the appearance of the vulva and compare some of the techniques described, seeking to increase the postoperative esthetic and functional satisfaction. Methods: A retrospective study with 7 patients undergoing sex reassignment surgery between August 2017 and February 2018 was conducted. The clitoris is constructed with the glans in the form of a trident, using the corona to build the corpus cavernosa of the clitoris and increase the area of erogenous sensation. A section of the prepuce is used to increase the coverage of the clitoris and cover the inner surface of the labia minora, which are defined with the use of sutures. Results: Adequate sensitivity and satisfaction with the result and capacity of orgasm in all patients were observed. There was no stenosis, fistula, or necrosis of the clitoris with this technique. Only 1 case needed an additional procedure for better esthetic definition. Conclusion: The technique presented leads to high patient satisfaction and erogenous sensitivity, with some advantages compared to other techniques. However, prospective studies with larger numbers of patients are needed to define a more effective surgical technique.

Step by step male to female transsexual surgery

ABSTRACT Introduction After the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long-term patient rehabilitation is maintained for at least two years. The indication for surgery is chronic discomfort caused by discord with the patient's natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty. The surgical conversion of transsexuals is the main step in the complex care of these problematic patients (1). This surgery was first described by Benjamin H, using a flap of inverted penile skin (2) and is considered the gold standard since then. Male-to-female transsexual surgical techniques are well defined and give good cosmetic and functional results. Sex reassignment surgery promotes the improvement of psychological aspects and social relationships as shown in the World Health Organization Quality of Life Assessment applied in the patients submitted to this procedure (3). Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing sexual intercourse and the capability of clitoral orgasm (4). Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts (5). In our Hospital, we use penile and scrotal skin flaps. Until now, 174 procedures have been performed by our team using this technique with high rates of satisfaction (3). Patients and methods We present a step-by-step male to female transsexual surgery. Conclusion Surgical gender reassignment of male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm (1). With this video we show step by step that a surgery using penile skin flaps is able to be performed with good cosmetic results.

Neovaginoplastias: uma revisão dos diversos métodos de tratamento / Neovaginoplasty: a review of different treatment methods

O propósito desta revisão foi analisar os diferentes métodos de neovaginoplastias que vêm sendo executados com o intuito de criar ou ampliar uma neovagina sem excessiva morbidade, a qual seja funcionalmente ativa e traga satisfação com relação a seu aspecto e sua função, promovendo o bem-estar. São descritas todas as possíveis causas de ausência da vagina, sejam elas anomalias congênitas ou mesmo adquiridas. Em vista disso, há uma grande diversidade de métodos terapêuticos propostos, o que indica que o resultado ideal ainda está para ser obtido.(AU)

The purpose of this review was to analyze different neovaginoplasty procedures that have been performed to create or enlarge a new vagina without excessive morbility, which is functionally and aesthetically pleasing, leading to wellbeing. In this issue are described different possible etiologies of vaginal absence, like congenital abnormalities or acquired ones. In this regard, therapeutic methods vary widely, which indicates that ideal results have yet to be obtained.(AU)

Propuesta de plan de cuidados para pacientes con cirugía de reasignación sexual / Proposal of a care plan for patients with sex reassignment surgery

Introducción: independientemente del nivel científicotécnico del médico que realiza la cirugía, de los recursos materiales de que se dispongan y de la tecnología de punta utilizada, no es posible una intervención quirúrgica exitosa sin la actuación de profesionales del cuidado competentes, con un profundo contenido humano y ético.Objetivo: proponer un plan de cuidados para pacientes con cirugía de reasignación sexual, integrando la teoría de las 14 necesidades básicas de Virginia Henderson y el Modelo de la adaptación de Sor Callista Roy.Métodos: se realizó un estudio descriptivo de corte transversal en una institución de salud del tercer nivel de atención durante el año 2011. El universo de estudio quedó constituido por personas de ambos sexos a las que se les realizó cirugía de reasignación sexual durante los años 2008 al 2011. Se utilizó el método observacional documental de historias clínicas, de donde se obtuvo la información necesaria. Las variables de estudio fueron necesidades humanas afectadas las que se evaluaron según la teoría de las 14 necesidades básicas de Virginia Henderson. El plan de cuidados se diseñó por la taxonomía diagnóstica de la North American Nursing Diagnosis Association (NANDA) y el Modelo de la adaptación de Sor Callista Roy. Resultados: las 14 necesidades básicas se encontraron afectadas en todas las personas estudiadas la valoración global y focalizada realizada generaron los 10 diagnósticos de enfermería precisos, igual número de objetivos y 64 acciones de enfermería con los que se cuidaron los pacientes durante el perioperatorio. Conclusiones: se concluyó que la aplicación en la práctica clínica de las teorías de Virginia Henderson y Sor Callista Roy orientó los cuidados y sustentaron la calidad de la atención de enfermería brindada a los pacientes con tratamiento quirúrgico de reasignación sexual(AU)

Background: regardless the scientific and technological level of the doctor that performs surgery, the material resources they have and the technology used, a successful surgical intervention is not possible without the performance of competent care professionals, with a deep human and ethical content. Objective: to propose a care plan for patients with sex reassignment surgery, integrating the theory of Virginia Henderson's 14 fundamental needs and Callista Roy's Adaptation Model. Methods: a descriptive cross-sectional study was conducted in a tertiary health institution during the year 2011. The study universe was composed of persons of both sexes to whom sex reassignment surgery was performed during the years 2008 and 2011. The documentary observational method of clinical histories was used, from which the necessary information was obtained. The study variables were affected human needs, which were evaluated according to Virginia Henderson's 14 fundamental needs. The care plan was designed by the diagnostic taxonomy of the North American Nursing Diagnosis Association (NANDA) and the Callista Roy's Adaptation Model. Results: the 14 fundamental needs were affected in all the persons under study; the global focused assessment conducted reported the 10 accurate nursing diagnosis, the same number of objectives and 64 nursing actions carried out for the care of the patients during the perioperative period. Conclusions: it was concluded that the application of Virginia Henderson's 14 fundamental needs and Callista Roy's Adaptation Model in clinical practice, oriented the care and sustained the quality of nursing attention given to patients with sex reassignment surgical treatment(AU)

Gender reassignment surgery - a 13 year review of surgical outcomes

PURPOSE: The aim of this study is to thoroughly report on surgical outcomes from 332 patients who underwent male to female gender reassignment surgery (GRS). MATERIAL AND METHODS: Records from 332 patients who underwent GRS from 1995 to 2008 were reviewed. All patients were submitted to penile inversion vaginoplasty with glans-derived sensate clitoroplasty. Mean age was 36.7 years (range 19-68 years). Surgical complications were stratified in 6 main groups: genital region, urinary tract, gastrointestinal events, wound healing disorders and unspecific events. RESULTS: Progressive obstructive voiding disorder due to meatal stenosis was the main complication observed in 40% of the patients, feasibly corrected during the second setting. Stricture recurrence was found in 15%. Stricture of vaginal introitus was observed in 15% of the cases followed by 12% and 8% of vaginal stenosis and lost of vaginal depth, respectively. Rectal injury was seen in 3% and minor wound healing disorders in 33% of the subjects. CONCLUSION: Regarding male to female GRS, a review of the current literature demonstrated scarce description of complications and their treatment options. These findings motivated a review of our surgical outcomes. Results showed a great number of adverse events, although functionality preserved. Comparision of our outcomes with recent publications additionally showed that treatment options provide satisfying results. Moreover, outcomes reaffirm penile inversion vaginoplasty in combination with glans-derived sensate clitoroplasty as a safe technique. Nevertheless, discussing and improving surgical techniques in order to reduce complications and their influence on patient's quality of life is still strongly necessary and theme of our future reports.