Fluidity models in ancient Greece and current practices of sex assignment

Abstract

Disorders of sexual differentiation such as androgen insensitivity and gonadal dysgenesis can involve an intrinsic fluidity at different levels, from the anatomical and biological to the social (gender) that must be considered in the context of social constraints. Sex assignment models based on George Engel's biopsychosocial aspects model of biology accept fluidity of gender as a central concept and therefore help establish expectations within the uncertainty of sex assignment and anticipate potential changes. The biology underlying the fluidity inherent to these disorders should be presented to parents at diagnosis, an approach that the gender medicine field should embrace as good practice. Greek mythology provides many accepted archetypes of change, and the ancient Greek appreciation of metamorphosis can be used as context with these patients. Our goal is to inform expertise and optimal approaches, knowing that this fluidity may eventually necessitate sex reassignment. Physicians should provide sex assignment education based on different components of sexual differentiation, prepare parents for future hormone-triggered changes in their children, and establish a sex-assignment algorithm.

Keywords: 5-alpha reductase deficiency; Androgen Insensitivity Syndrome; DSD; Gonadal dysgenesis; Sex Assignment.

Fig. 1

The typical differentiation pathway from the bipotential gonad to the typical male and female anatomy, with some of the involved genes. (Modified with permission from Elsevier, from Acherman JC, Hughes IA. Pediatric disorders of sex development. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elselvier, Inc.; 2016: 893–963.).

Fig. 2

Hermaphroditus. A Hellenistic statue of Hermaphroditus (marble copy of a fresco from Herculaneum). Source: Wikimedia Commons.

Fig. 3

Daphne, Apollo, and Daphne, terracotta sculpture by Massimiliano Soldani, c. 1700, Cleveland Museum of Art. Source: Wikimedia Commons.

Fig. 4

Algorithm for responsible management: a fluidity model for providing sex assignment education based on different components of sexual differentiation—medical, surgical, and ethical considerations must be considered and balanced against patient and parent understanding and sociocultural expectations. The Greek models may serve as context for this last factor. (Adapted with permission from Pediatric Endocrinology Reviews, from Chen MJ, Vu BM, Axelrad M, et al. Androgen Insensitivity Syndrome: Management Considerations from Infancy to Adulthood. Pediatric endocrinology reviews: PER. Jun 2015;12(4):373–387).