Intersexuality

Intersexuality

* Understanding Intersex
* Gender Identity: Nature vs. Nurture
* The Ethical Questions
* Discussion
* Papers


An advance warning

* For anyone who has done the reading, this will not come as a shock, but we will be discussing sex and gender today.
* Some of the video clips depict surgeries and genitals (sometimes blurred, sometimes not).
Understanding Intersex

* Simplest definition: intersex is a congenital anomaly of the reproductive and sexual system.
* There are many differences between those who are intersexed. It is difficult to point to any set of characteristics of intersexuality, though the most common characteristic is ambiguous genitalia.

A word on language…

* Hermaphrodite vs. Intersex
* “true hermaphrodites” in a medical context

Ambiguous Genitalia

* Generally, this is what tips off medical staff to the possibility of a newborn being intersexed.
* Quite simply, this is when the reproductive organs do not present themselves as they usually do. This can be because of the size or shape of the genitals.

Androgen-Insensitivity syndrome (AIS)

* Also known as “testicular feminization.”
* Though the genes read as XY, the androgen receptors in the body cannot “read” the masculinizing hormones the testes produce. Because of this, these “male” children's anatomy both in utero and after birth develop in a “feminized” manner.
* Often not discovered until puberty, when menstruation does not occur.

Progestin Induced Virilization

* Progestin was a drug administered to women in the 1950s and 60s to help prevent miscarriages.
* The drug would be converted to androgen by the prenatal XX child, which could result in the “masculinization” of the child. Possible side effects are enlarged clitoris, development of a phallus, and/or the fusing of the labia.

Progestin Induced Virilization

* In every case, ovaries and the uterus develop, though in some cases the vagina and cervix do not develop.
* After birth, a normal female puberty occurs.
* While Progestin is no longer used to prevent miscarriages (it was not effective), it along with estrogen is the primary components of birth control pills. Some take progestin-only birth control.

Congenital Adrenal Hyperplasia (CAH)

* An anomaly of adrenal function causes the synthesis and excretion of an androgen precursor, which begins the “masculinization” of an XX person.
* Since this process is metabolic in nature, the masculinizing effects continue after birth.
* Phenotype varies along the whole spectrum.

Klinefelter's syndrome

* Most men inherit a single X chromosome from their mother, and a single Y chromosome from their father.
* Men with Klinefelter syndrome inherit an extra X chromosomes from either father or mother.

A Little on Genetics

* Your DNA is a combination of the DNA of your parents.
* Generally, women receive an “X” chromosome from each parent; this is known as “46 XX”
* Most men receive an “X” from their mother and a “Y” from their father. This is known as “46 XY”

A Little More on Genetics

* Men with Klinefelter, with their “extra” “X” has what is known as “47 XXY.”
* Other variants are “45 XO” (“blank”), “47 XXX” (super-female) and “47 XYY” (super-male)

Hypospadias
For those who wonder if they are intersexed…
The Phall-o-meter
Common Treatments

* Most of the attention in the intersex debate is focused on cases of AIS and CAH.
* Traditionally, the treatment of these forms of intersex was to “correct” the genitals.
* Those with a “micropenis” would be surgically reassigned as females, while those with enlarged clitorises would have a cliterectomy.
* These surgical treatments would really occur in stages. Generally one operation would not be enough to make genitals that appeared normal, so procedures would occur for years.
* Anecdotal evidence supports that most with ambiguous genitals were assigned as females because it is easier to “dig a hole than build a pole.”

Components of a treatment

* Surgery on the genitals (can occur many times) and possibly other body parts (such as breasts after puberty)
* Hormone cocktails
* “Psychosocial” rearing according to norms for the assigned gender.

Gender Identity

* The Case of John/Joan & John Money in general
* Nature vs. Nurture
* What is at stake?

The Ethical Questions

* Involves paternalism, informed consent, and deception
* Also includes societal questions about the nature of gender. Raises issues about our understanding of sexual matters, as well as social conventions such as marriage.

The Readings
Fausto-Sterling

* What is her thesis?
* What do you think about it?

Letters

* Bird’s objection: How would you respond?

Intersexuality.ppt

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Medical Genetics

Medical Genetics

Presentation lecture by:Dennis Anderson
Oklahoma City Community College
Human Anatomy and Physiology II
Mitosis

* Produces daughter cells with 46 chromosomes
* Used in growth and repair
* DNA is duplicated
* Doubled chromosomes form from duplicated DNA
* Each cms has 2 identical chromatids

Chromatid
Mitosis Metaphase
Chromosomes separate
Meiosis
Chromosomes line up in a double row.
Each each daughter cell gets doubled chromosomes
Double Filed Chromosomes
Gene
Allele
Dwarfism = D
Normal height = d
DD = Dwarfism
Dd = Dwarfism
dd = Normal height
Examples of Alleles
Dwarf Band

Dominant & Recessive Alleles
Homozygous
Heterozygous
Genotype
Phenotype
Codominant
Karyotype
Homologous Chromosomes
Mutation
Mutagen
Agent that causes mutations
Cigarette smoke
Pesticides
X-rays
Ulatraviolet light
Nuclear radiation
Homologous Pairs Separate
Fertilization
Nondisjunction
Trisomy
Sex Chromosomes
Autosomes
Chromosomes 1-22
X-Linked Traits
Normal Male
Normal Female
Trisomy 21
Down Syndrome
* Large tongue
* Flat face
* Slanted eyes
* Single crease across palm
* Mental retardation
o Some are not

Maternal Age & Down Syndrome
Trisomy 18
Edward Syndrome
* Heart defects
* Displaced liver
* Low-set ears
* Abnormal hands
* Severe retardation
* 98% abort
* Lifespan < 1 year
Trisomy 13
Patau Syndrome
* Cleft lip and palate
* Extra fingers & toes
o polydactylism
* Defects
o Heart
o Brain
o Kidneys
* Most abort
* Live span < 1 month

Klinefelter Syndrome
* Breast development
* Small testes
* Sterile
* Low intelligence
o Not retarded
Klinefelter Website
Turner Syndrome

* Short
* Not go through pruberty
* Produce little estrogen
* Sterile
* Extra skin on neck
Fetal Testing
Sickle Cell Anemia
* RBCs sickle shaped
* Anemia
* Pain
* Stroke
* Leg ulcers
* Jaundice
* Gall stones
* Spleen, kidneys & lungs
* Recessive allele, s codes for hemoglobin S
o Long rod-like molecules
o Stretches RBC into sickle shape
* Homozygous recessive, ss have sickle cell anemia
* Heterozygous, Ss are carriers

Hemophilia
Blood clotting impaired
Recessive allele, h carried on X cms
X-linked recessive trait
More common in males
Albinism
Amino Acids
Melanin Pigment
Enzyme
PKU Disease
Molly’s Story
Phenylalanine
Tyrosine
Enzyme

Medical Genetics.ppt

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Male and Female Genitalia

Male and Female Genitalia
Presentation Lecture by Jennifer Coleman, Assistant Professor of Nursing
Arkansas Tech University.

* Health Assessment

Common Chief Complaints
* Urethral discharge
* Palpable mass
* Erectile dysfunction
* Penile lesion
* Scrotal pain

Inspection

* Hair distribution
* Urethral meatus
o Location, discharge
* Inguinal area
o Bulges, masses
* Penis
o Size, shape, lesions, swelling, inflammation
* Scrotum
o Size, shape, lesions, inflammation, swelling, nodules
Inspect the Glans and Urethral Meatus
* Compress meatus
o Check for proper positioning of urethral opening
o Check for drainage – urethral culture
* Skin pink and smooth
Transillumination

* Light from behind scrotum
* Normal - Does not transilluminate
* Hernia – Pink or red glow
* Hydrospadias - Translucent

Palpation

* Penis
o Assess for tenderness, pulsations, masses
* Urethral meatus
o Assess for discharge
* Scrotum
o Assess for masses, tenderness, spermatic cord
* Inguinal area
o Assess for hernias

Inspect and palpate the scrotum

* Patient holds penis out of the way
* Note skin, lumps, nodes
* Testes: slide easily, oval, firm, movable
* Epididymis: feels discrete, softer than testis, smooth

Auscultation

* Not routinely done, but can add to assessment findings
* Scrotum
* Abnormal findings
o Presence of bowel sounds may indicate indirect inguinal hernia

Abnormal Finding Examples

* Hypospadias and Epispadias
* Penile lesions and Urethral discharge
* Hydrocele, Spermatocele, Empty scrotal half, Acute Orchitis, Scrotal Edema, Torsion of the cord, Acute epidymitis, Testis Tumor
* Hernias
* Alopecia, Lice or nits present

Hypospadias

* Urethral meatus open on ventral (under) side of glans, shaft or penoscrotal junction
* Do not circumcise until surgically corrected

Epispadias

* Meatus opens on dorsal (upper) side of glans or shaft
* Less common than hypospadias

Syphilitic Chancre

* Silver, small papule - erodes to red ulcer with yellow, serous discharge
* Nontender base
* Lymph nodes enlarged & nontender

Genital Herpes

* Clusters of small vesicles, surrounding erythema
* Often painful, erupt to superficial ulcers
* 1st infection lasts 7-10 days
* Virus remains dormant indefinitely
* Recurrent infection lasts 3-10 days

Genital Warts

* Warts
* Painless, grapelike clusters
* May look like skin tags
* One of the most common STD’s

Carcinoma of Penis

* Red, raised warty growth or an ulcer with watery discharge
* Necrose and slough
* Usually painless
* Usually on glans
* Lymph nodes commonly enlarged

Hydrocele

* Painless swelling
* Enlarged mass, transilluminates translucent
* Communicating vs. noncommunicating (intermittent or constant bulge)
* Common <2 y.o. - often disappears spontaneously

Spermatocele

* Cyst in epididymis (generally small)
* Painless
* Does transilluminate
* round, freely moveable (may feel like a third testis)

Empty scrotal half

* True cryptorchidism – testes never descended
* Physiologic cryptorchidism - absence of testis in scrotum, but can be milked down
* 3-4% at birth, most will descend in 1st mo. (much higher percentage with prematurity)
* Decrease spermatogenesis to infertile by 6 yrs.

Acute Orchitis

* Acute inflammation of testis – most commonly from the mumps
* Pain – sudden onset, swollen testis, fever
* Potential for infertility

Scrotal Edema

* Usually occurs with systemic edema (CHF, renal failure)
* Also with local inflammation
* Tenderness, reddened, taut with pitting

Torsion of the cord

* Sudden twisting of the spermatic cord
* Rare after 20 y.o.
* Usually on left side
* Blood supply is cut off – ischemia and engorgement - very painful
* Emergency – requires surgery
* Cremasteric reflex absent

Acute epidymitis

* Acute infection of epidiymis
* Severe pain of sudden onset, rapid swelling and fever
* Reddened scrotum
* WBCs and bacteria in urine

Testis Tumor

* Usually painless lump
* Increase in local nodes common

Hernia

* Internal anatomy of inguinal hernia
* Loop of bowel protruding through weak muscle
* Possible pain
* Swelling
* May be congenital or acquired

Palpate for hernia

* Inguinal canal
* Ask patient to “bear down”
* Nl: feel no change
* Abnl: feel mass bump into/push against side of your finger

Newborn

* Scrotum pink with rugae (preterm will have smooth scrotum)
* Cremastric reflex strong
* Check for undescended testes, hydrocele, inguinal bulge

Pediatric Considerations

* Circumcision is considered a personal/cultural/religious decision by parents (~70-80% in US)
* Start TSE at ~13-14 years of age
* Undescended testicles increase risk of cancer
* Do not retract foreskin 1st 3 months d/t risk of tearing membrane

Developmental Considerations

* Infants
o Prenatally – testis develop in abdomen then migrate down into scrotum beginning at week 30
* Adolescents
o Puberty ~ 9 ½ yrs- 13 ½ yrs.
o 1st sign of puberty are enlargement of testes, next is pubic hair then penis inc. in size
o Sexual Maturity Ratings – p. 717

Gerontological Variations

* Thinner, gray pubic hair
* Decreased testosterone levels
* Penile and testicular atrophy
* Scrotal rugae decreases
* Slightly decreased spermatogenesis
* Increased time to obtain erection
* Increased risk for impotence
* Benign prostatic hypertrophy - 1 in 10 the prostate gland will increase in size ~ 40 y.o.

Testicular Self Exam (TSE)

* Exam every month
* Exam with warm shower will relax scrotal sac
* Testicular cancer is rare but occurs most commonly in young men (15-35 y.o.)
* Caucasians 4 times more likely to develop testicular cancer
* ~100% cure rate with early detection

Anus

* Anal canal is outlet of GI tract
* Canal is surrounded by 2 layers of muscle
o internal sphincter - involuntary control
o external sphincter - voluntary control
* External inspection looks moist and hairless (check for skin breakdown with valsalva maneuver)
* “ Anal Wink test”

Rectum

* 12 cm long
* distal portion of large intestine

Pediatric Considerations

* 1st stool passed by newborn is dark green (meconium) - indicates anal patency - usually at 24-48 hours
* Infants pass stool by reflex (gastrocolic reflex) with each fdg. - nerves fully myelinated by 1.5 - 2 years old for voluntary control

Prostate

* Gland which surrounds the bladder neck and urethra
* Secretes milky fluid which helps sperm remain viable

Prostate Gland

* Puberty - rapid increase to > double size then stabilizes through adulthood
* Common to increase in size with older adults - gradually impede urine output - BPH
* Most common non-skin cancer in America, affecting 1 in 6 men
* African American men are 61% more likely to develop prostate cancer
* http://www.cancer.gov/cancertopics
* Prostatitis –
o infection in the prostate, most common cause of UTIs in men
o fever, chills, burning during urination, or difficulty urinating

Palpate Prostate Gland

* Size
* Shape
* Surface
* Consistency
* Mobility
* Sensitivity

Palpation of Anus & Rectum

* Gloves with water soluble lubrication
* Approach at an angle with finger
* Palpate muscular ring by rotating finger
* Use thumb to help check bulbourethral glands
* Inspect stool (brown and soft)

Abnormal Findings

* Pilonidal Cyst or Sinus
o Midline over coccyx
o Dimple opening with visible tuft of hair
o May be a palpable cyst – sinus develops when advanced
o Congenital – but often not diagnosed until 15-30 years old

Abnormal Findings

* Check for anorectal fistula (abnormal passage from GI tract, normally caused by an abcess)
* Rectal prolapse - rectal mucous membrane protrudes through anus
* Hemorrhoids (external & internal, thrombosed)
* Pruritus Ani - intense perianal itching
o children - pinworms
o adults - fungus

Abnormal Findings

* Polyps of rectum
o Relatively common growth
o Not easily palpated
o Proctoscopy and biopsy needed to screen for malignancy
* Carcinoma of the rectum
o Malignant neoplasm
o Asymptomatic

Female Genitalia

* Common chief complaints
o Uterine bleeding
o Vaginal discharge
o Urinary symptoms
o Pelvic pain

External Inspection

* Pubic hair distribution
* Skin color and condition
o Mons pubis and vulva
o Urethral meatus
o Vaginal introitus
o Perineum and anus

Palpation of External Genitalia

* Labia
* Urethral meatus
* Skene’s glands (normally unable to visualize)
* Bartholin’s glands (normally unable to visualize)
* Vaginal introitus
* Perineum

Bartholin’s Gland Infection

* Local pain (may be severe)
* Skin over abscess red and hot
* Can express purulent discharge
* Often complication of gonococcal infection

Internal Inspection

* Order of internal examination
o Speculum examination - obtain specimens
o Bimanual examination – water soluble lubrication
o Rectovaginal examination

Lithotomy Positioning

* Elevate head and shoulders slightly to improve comfort - also provides opportunity for patient to maintain eye contact
* Slide patient to very end of table
* Proper draping very important

Speculum Examination of the Cervix

* Use of speculum
* Characteristics of assessment
o Color
o Position
o Size
o Surface characteristics
o Discharge
o Shape of cervical os

Cervix

* Mucosa is pink and even
* 2nd mo. pregnancy is blue (Chadwick’s sign)
* After menopause is pale
* Note Os

Cervical Cancer and Nabothian Cysts
* HPV – main risk factor for cervical cancer
* Lack of regular Pap tests
* Weakened immune system
* Over the age of 40
* BC pills for 5 or more years with HPV
* http://www.cancer.gov/cancertopics

Cervix Specimen Collection
Collecting Specimens

* Pap smear/ Thin-layer preparation (liquid-based)
o Endocervical
o Cervical
o Vaginal
* Gonococcal/Chlamydia culture
* Saline mount (Wet Prep)
* Acetic Acid Wash (HPV – human papilloma virus – genital warts)
* Anal culture

Vaginal Discharge

* Normal – small amount, clear or cloudy, nonirritating
* Profuse, watery, gray-green & frothy - trichomoniasis
* Thick, white & curd-like - candidiasis

Uterine Positions

* Anteverted - usual position
* Anteflexed - usual position
* Midposition
* Retroflexed
* Retroverted
* See page 777.

Rectocele

* Rectum (under vaginal mucosa) is prolapsed into vagina
* Pressure felt in vagina
* Constipation possible

Cystocele

* Prolapse of bladder (under vaginal mucosa) into vagina
* Pressure felt in vagina
* Stress incontinence

Pediatric Considerations

* Newborn - engorged external genitalia d/t maternal estrogen
* Puberty - estrogen stimulate secondary sex characteristics
* 1st signs are breast and pubic hair development
* Begins 8.5 to 13 years
* Sexual Maturity rating – p. 411 & 760

Pregnancy

* Primagravida - pregnant for the 1st time
* Primipara - first delivery
* Multigravida - pregnant for >1 time
* Multipara - > 1 delivery
* Gravida - pregnancy
* Para - delivery
* AB - abortion (spontaneous/elective)

Pregnancy

* Chadwick’s sign – blue cervix
* Goodell’s sign – cervix softens
* Mucus plug – cervical canal
* Cervical & vaginal secretions – increase, thick, more acidic
* May increase risk of candidiasis (yeast) infection

Gerontological Variations

* Menopause - cells in the reproductive tract are estrogen dependent
o Low estrogen levels
o Cessation of menses
o Generalized atrophy of external and internal female organs
o Thinning of vaginal epithelium
+ Decrease in lubrication
+ Wall becomes drier and itchy
+ Increase risk for bleeding & vaginitis

Copyright 2002, Delmar, A division of Thomson Learning
Male and Female Genitalia.ppt

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