Monday, March 3, 2014

Classic Manuscripts in Urology: Reiner and Gearhart, 2004

William G. Reiner, MD, was a Professor of Psychiatry and Urology at Johns Hopkins who, working with John P. Gearhart, MD, Professor and Director of Pediatric Urology at the Brady Urological Institute at Johns Hopkins, had a special interest in the development of children and adolescents with disorders of sexual development.   Dr. Reiner is currently at the University of Oklahoma, however he continues to work to improve the psychosocial development of these children by exploring gender identity, the impact of genital appearance and function, as well as urinary function and their impact on these children.  We review this seminal work:

Reiner WG, Gearhart JP.  Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth.  New England Journal of Medicine. 2004 Jan 22;350(4):333-41.  

In this manuscript, Drs. Reiner and Gearhart examined 16 male children born with cloacal exstrophy.  Due to the marked phallic inadequacy or, in some cases, absence of a phallus, genetic males born with cloacal exstrophy were often assigned to female sex in the neonatal period. Fourteen of the 16 males underwent surgical, social and legal assignment to female sex.  For two patients, the parents refused gender reassignment.

At last follow-up, eight of the 14 subjects assigned to female sex declared themselves male, six of whom reassigned themselves to male sex.  Five patients were living as females and three had an unclear sexual identity.  Interestingly, all 16 subjects had moderate-to-marked interests and attitudes considered typical of males.

Take Home:  This manuscript was and is incredibly important in the discussion of gender identity.  Specifically, this manuscript addresses disorders of sexual differentiation, but it has been touted as some of the best evidence regarding androgen-imprinting and gender identity.  It has been mentioned in the national and international debate on same-sex marriage and shared benefits.  In local news, this manuscript has been cited in the discussion of gender identity as Maryland debates a new Gender Identity Bill.

Dr. Reiner is quoted on, "I would argue that there is evidence that sexual orientation in the male has a strong tendency to be affected by and at least partly induced by androgens prenatally (but there is no evidence that female sexual orientation is brought about prenatally). That said, homosexual males are also exposed to probably the same dose of androgens as heterosexual males. Thus, sexual orientation is too complex in its origins at present to understand."

Classic Manuscripts in Urology will be posted on this blog on regular basis.  These articles are meant to highlight the achievements of our predecessors, recognize the work from which we build our careers and stimulate new conversations and discussion on a variety of urological topics.  Please feel free to comment on this manuscript, help point out its strengths and weaknesses, or suggest a new manuscript and topic. 

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