How big is a hermaphrodite's penis? Hermaphrodite: the structure of the reproductive organs

There are many actions that people perform automatically, without thinking about this or that issue. For example, when filling out a questionnaire, a person automatically indicates data on gender, age, race, etc.

For many people, the concept of gender does not bring any doubt that a woman is a female and a man is a male. But not everything is so categorical, as it seems, because there is a group of people who do not fit into the general framework.

These are hermaphrodite people and for them such an item in the questionnaire is a big question that is not so easy to answer. Let's try to figure out who hermaphrodite people are, how they look and how they differ from others.

Hermaphrodites are individuals who have the sexual characteristics of both sexes, i.e. both women and men. In relation to hermaphrodites, it is also customary to use the definition of "androgyne", translated from Greek, meaning "aner" - a man, "gyne" - a woman.

The concept of hermaphroditism originates from ancient Greek legends. When the son of the gods Aphrodite and Hermes was born, the boy was named such a big name as Hermaphrodite, which was coined from the two names of his parents (Phrodite from Aphrodite and Hermes from Hermes). At the age of fifteen, a nymph who lived in water fell in love with a young man, he also kindled with a reciprocal passion and asked the gods to unite them into one, the gods fulfilled his request. And so the first hermaphrodite appeared.

And already in the Middle Ages, this kind of sexual metamorphosis was considered the work of evil spirits, and according to the inquisitorial practice of the 16th-17th centuries. cases of persecution of hermaphrodites have been identified. For example, in the 16th century in Darmstadt, a baby of dubious sex was baptized, who was given the name Elizabeth, and then John, after which John again turned into Elizabeth, who, in order to exclude such transformations, was burned at the stake.

Features of the body structure

It is known that each human embryo transforms into a male or female fetus, and during development in the uterus has a natural tendency to take on female flesh, or is subject to change on the basis of chromosomes, which determine the sex of the unborn baby. However, one should not exclude genetic and hormonal causes that can affect the development of the embryo or fetus and lead to the birth of a non-standard cub.

In some species of animals, hermaphroditism is the norm, in humans the situation is different, and such a pathology is primarily a violation of sexual differentiation. Despite the fact that among people this phenomenon is quite rare, it still has a certain percentage of the risk of improper development of the human body in our time. According to statistics, a similar pathology occurs in one out of two thousand newborns.

A hermaphrodite is a person in whose body there may be the genital organs of a man, and the breast of a woman and instead of the ovaries there may be a mixture of tissues from them and from the testicles. According to such features of the human body, it is very difficult to determine the sex, because the hybrid tissue is not capable of synthesizing hormones, since it does not have eggs and follicles, therefore hermaphrodites cannot reproduce and live in a life of sexual uncertainty.

It is also possible to have mixed external genital organs with the correct formation of the gonads according to the female or male type.

The difference in the first and second cases is explained by the varieties of hermaphroditism:

• true hermaphroditism;
• pseudohermaphroditism.

It happens that a person is born with both a penis and a vagina, that is, with full-fledged female and male genital organs, while having both ovaries and testicles. But these individuals still do not have the ability to reproduce, since their genitals are inactive.

To date, there is only one such case, which was described in The New York Journal of Medicine.

One interesting human being (a hermaphrodite) had both full sexual organs, ejaculated sperm and experienced menstruation, and was also able to have normal sexual relations with both a man and a woman. Such an amazing phenomenon was revealed when a twenty-eight-year-old woman was arrested for prostitution.

Pseudohermaphroditism

Pseudohermaphroditism is the following cases:

• when the genitals of both men and women are formed in such a way that they outwardly resemble the genitals of the opposite sex, while their internal structure is normal;
• a hermaphrodite woman is faced with the problem of the development of the clitoris, it grows to an enormous size, to the point that it is mistaken for a penis;
• in hermaphrodite men, the scrotum and testicles are pulled inside and become like two skin folds that resemble the labia;
• there are cases when men, as a result of random atrophy of the testicles, showed external female signs (for example, a female figure and appearance).

Causes of the disease

The following reasons can lead to the birth of a child with signs of a hermaphrodite:

The desire to be cured and get rid of such a disease in many people is accompanied by strong psychological upheavals, because in fact sex adjustment is their second birth in a completely different body. The life of hermaphrodites in a new capacity can be real torture, so the help of a psychologist in this case is mandatory.

However, not every person with such a problem is able to pay for quality medical care, so he continues to live with signs of hermaphroditism. He is constantly faced with such problems as: replacing documents, transferring to another educational institution, medical care, etc. And yet this may seem like a trifle before later life, because a person must adapt to think about his personality, develop and not lose his sense of own dignity.

The life of famous hermaphrodite people

During the existence of the first hermaphrodites on earth, fate was cruel for them. In the Middle Ages, people with deviations from the norm were subjected to extermination, and bisexual people were treated with particular cruelty.

For example , Antide Kollas, declared in 1559 a hermaphrodite, was deprived of liberty and examined by doctors. They could not explain the reasons for such an abnormal state of her body and she was accused of having entered into a relationship with Satan, for which she was burned.

A few years later, a law was put forward that people with such features could use the right given to them and declare the choice of one flesh, but without changing their decision later.

Attitudes towards hermaphrodites often depended on the status of their family.. An example of this is the life of Charles de Beaumont, Chevalier d'Eon, also known as Geneviève de Beaumont and Mademoiselle d'Eon. This man was a pseudo-hermaphrodite and had a significant impact on the politics of France in the 18th century. He chose the gender of a man, lived for 82 years, and showed no interest in any of the women, the same attitude was towards men, because his true gender was a mystery to him. Despite the fact that Charles made a huge contribution to politics, for unknown reasons he was expelled and lived in London as a woman, but after examination by the royal doctor, who announced his female gender, he was allowed to return on the condition that he take a vow of monasticism.

In the 19th century there were attempts by scientists to find out the phenomenon of hermaphroditism, but it was not easy to diagnose this disease. For example, an American from a wealthy family, Marie Dorothy, was brought up as a woman, despite the fact that she was a hermaphrodite, and only when a question arose with a will in which a man was declared the heir, doctors began to examine her. Two doctors recognized her as a woman, three as a man, and one as both a woman and a man. The court ruled that half of the state is due to the male half of Marie Dorothy.

Very soon, hermaphrodites became popular on open-air deformity rides. Public displays of body parts were forbidden, so hermaphrodites grew hair on the right side of the body, like men, and shaved the left side, to represent a woman's appearance. Notable hermaphrodite actors of the time were: Diana/Edgar, Donald/Diana and Bobby Cork.

In 1966, the hermaphrodite Bill Ruskam, who later became a woman and took the name Rene Richards, became famous thanks to the big sport and the scandalous defense of his own rights, because the topic of the mismatch of the sex of several participants in the athletics competition was raised, because of which the European sports the federation decided to conduct special tests. In order not to undergo a humiliating procedure, many athletes stopped participating in competitions, the rest easily agreed, believing that any manifestations of hermaphroditism would only give them popularity.

Renee Richards also decided to participate in a tennis tournament, but she refused to take tests that determine the real gender of the participants in the competition and brought the case to court. However, she still had to undergo an examination, since it was not limited to one physical examination and was based solely on the results of analyzes of chromosomal cells in the oral mucosa. René Richards' measurements were impressive: 80 kilograms of weight and 185 centimeters of height; due to her physical fitness and stamina, she was an excellent opponent for both male and female players, and achieved tremendous success in her sports life.

Another well-known hermaphrodite of our time is Caster Semenya, a South African runner who resisted the American Federation's decision to ban people with hermaphroditism from international competition. After a series of tests passed, she was still classified as a woman, she competed and for a long time no one attached importance to the characteristics of her body.

The biggest scandal erupted on August 19, 2009, when Kaster Semenya received a gold medal at the World Championships in Berlin in the 800 meters; many drew attention to the absence of the female figure of the athlete, as well as male facial features. But despite everything, the famous runner has cemented her status as an athlete and has become the most famous hermaphrodite in sports in recent years.

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In rare cases, children are born with indistinctly differentiated primary sexual characteristics. In such a situation, a delicate medical approach is extremely important, since gender plays a key role in shaping a sense of self-awareness. Sexual differentiation is the process of physical changes in the embryo, as a result of which it acquires male or female primary sexual characteristics. Usually this process develops in one direction.

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Photo gallery: Hermaphrodite: the structure of the reproductive organs

However, sometimes sexual differentiation can be disturbed, and at birth it can be difficult to determine the child's gender. Hermaphrodite, the structure of the reproductive organs - what can happen to a child?

Basic terms

The term "hermaphrodite" is used to describe an individual who has both female and male characteristics. In some animal species, this is the norm. In humans, this pathology refers to violations of sexual differentiation.

Hermaphroditism

The word "hermaphrodite" comes from the name of the god, the son of Hermes and Aphrodite, according to ancient Greek mythology, united in one body with a female nymph. In medicine, this term is used to refer to certain types of intersex conditions:

True hermaphroditism

It is characterized by the development of both male and female reproductive organs in the fetus. Such an individual has both male and female gonads, and in some cases, a combined sex gland (ovotestis), which has tissue elements of the ovaries and testicles. True hermaphroditism is very rare. Only about 400 such cases are described in the world medical literature. These patients showed significant variability in the structure of the internal and external genital organs. Most newborn hermaphrodites, however, had more pronounced male characteristics.

Hermaphrodites

Pseudohermaphroditism

It is characterized by the presence of mixed external genitalia, while the gonads are formed correctly according to the male or female type.

Pseudohermabooditism

Pseudohermaphroditism is a group of pathological conditions in which an individual has external signs of both sexes, and the gonads are formed according to the male or female type. Such people have either testicles or ovaries, and not both at the same time. Pseudohermaphroditism is a fairly rare disease, but it is much more common than true hermaphroditism. There are two main types of pseudohermaphroditism: male and female. In female hermaphroditism, the enlarged labia and clitoris resemble the scrotum and penis.

The reasons

The sexual duality of male pseudohermaphrodites can be due to several reasons, for example, a violation of the formation of testicles during embryonic development (gonadal dysgenesis), insensitivity of body tissues to testosterone, and a deficiency of enzymes that ensure the reaction of tissues to testosterone.

Female pseudohermaphroditism

Female pseudohermaphrodites have a female chromosome set (46, XX), but their external genitalia are formed partially or completely according to the male type. They may have a hypertrophied clitoris that resembles a penis. The vaginal opening is often closed. The masculine appearance is usually due to excessive production of male hormones by the adrenal glands during embryonic development.

enzyme deficiency

The cause of this unusual disease may be a violation of the production of enzymes by the adrenal glands, most often 21-hydroxylase. This enzyme is essential for the production of two essential adrenal hormones, cortisol and aldosterone. With a deficiency of 21-hydroxylase, these hormones are produced in insufficient quantities. The body reacts to hormonal imbalance by increasing the production of adrenocorticotropic hormone, which in turn stimulates the function of the adrenal glands.

male sex hormones

With an increase in the level of adrenocorticotropic hormone, the adrenal glands are activated, producing among other male sex hormones - androgens. Under their influence, male characteristics appear in the female body. Children with these abnormalities require replacement therapy with cortisol and aldosterone analogues throughout their lives. However, it is impossible to replenish the missing enzyme. If a child has sexual duality, a decision must be made whether he will be male or female. In this case, the interests of the child must be taken into account. Sexual duality happens, it is obvious already at birth. Therefore, it is extremely important to take urgent measures. Indelicate treatment of a hermaphrodite child can lead to serious problems for both him and his parents. Appropriate treatment is usually prescribed immediately after the baby is born.

Boy or girl?

All mothers and fathers want to know what gender their newborn is. When in doubt about this, a quick answer should not be given. However, it can be difficult for healthcare workers not to answer the main question of parents - they are forced to say whether it is a boy or a girl.

Hermaphrodites

Delayed with a decision

The difficulty also lies in the fact that the decision on gender, made immediately after birth, is very difficult to change later. From the very beginning, parents and relatives treat boys and girls differently. This difference is immediately apparent - for example, newborn boys are dressed in blue clothes, and girls - in pink. Moreover, a child's awareness of his gender is formed by about one and a half years. Therefore, in some cases it is better to postpone the announcement of the sex than to make a hasty and incorrect decision.

Psychological consequences

Doctors and patients should think about the future and take into account that a person's critical attitude towards his appearance - and especially towards gender - can lead to serious psychological consequences.

Childhood

Hermaphrodite children may become aware that they are different when they begin to socialize with their peers at school. They may also notice their parents' concerns about their sexual duality.

puberty

Puberty is an important developmental stage for every person. Problems at this age related to gender identity or appearance are well known and can be very traumatic. In hermaphrodites, puberty can be even more difficult. Some of them may delay puberty. Others may be concerned about noticeable changes in the body, such as the growth of facial hair and enlargement of the clitoris in a girl, the development of the mammary glands in a boy.

Gender Establishment

Before making a decision about choosing the sex of a hermaphrodite, the doctor should discuss in detail with the parents what is best for the child. The correct tactic of action in relation to a hermaphrodite child involves refraining from a hasty statement about his gender.

Council

For each patient, a consultation is held with the participation of pediatricians, as well as specialized specialists. Based on genetic studies and ultrasound results, the most acceptable gender for the child is determined. Ultrasound examination allows visualization of internal organs, such as the uterus or testicles that have not reached the normal position. Parents often experience a variety of emotions: shock, helplessness, irritation or fear. This difficult situation requires thorough discussion and conversations with parents.

Decision-making

Doctors sometimes take more than one day to decide which gender is most appropriate for a child. At the same time, given the concerns of parents, this should take as little time as possible. Until a final decision is made, no birth certificate can be issued. Until the final conclusion, all interested parties (including friends and relatives) in relation to the child should refrain from using words indicating gender, such as "he" or "she".

Parent Involvement

The final decision regarding the gender of the child is made jointly with the parents. This takes into account the chromosome set, heredity, enzyme activity, as well as the features of the anatomy and physiology of the body. It can be difficult to convey this information to the minds of relatives. However, it is up to the experts involved in solving this problem to state the key points as clearly as possible, while showing empathy and sympathy. The final decision should be the choice of a sex with which the child can live safely all his life. More often, experts recommend raising a child as a girl. This is due to the fact that it is easier for female hermaphrodites to correct the external signs of the male sex with the help of plastic surgery. As a rule, in the future they successfully fit into society as women. Quite different is the feminized boy, whose appearance is difficult to change enough to give him masculine features. Therefore, it is preferable to raise such a child as a girl. In the future, he will look like an ordinary girl, and later like a woman (however, she will not be able to have children). By law, the child's birth certificate will indicate the female gender. If such a decision is made, all testicular tissue is removed. First, because the testicles can produce testosterone, which can lead to the manifestation of some male characteristics (for example, the growth of facial hair). Secondly, tumoral changes can be observed in the testicular tissue at a later age. If the decision is made to raise a hermaphrodite child as a boy and he has a very small penis (micropenis), treatment should begin as soon as possible. Thus, it is possible to achieve that, as he grows older, he will form a male appearance close to the norm.

looking ahead

When making any decision, it is necessary to think about the future, assuming what kind of life the child will lead in the future and how he will adapt in society.

Instruction

Hermaphroditism causes difficulties in assigning an individual to any particular sex. It is a form of intersexism. Hermaphroditism has been known since ancient times. This phenomenon lies at the basis of beliefs common in the East and West.

According to one of them, Hermes and Aphrodite had a son of extraordinary beauty, his name was Hermaphrodite. When the young man was fifteen years old, the nymph Salmanis passionately desired him, but her love was not mutual. The nymph was inconsolable and, at her request, the gods united her with Hermaphrodite together, creating a same-sex creature.

If we consider hermaphroditism from a medical point of view, then there is nothing special here, at least in our time. The development of such an embryo is no different from the development of a normal child. However, already at the sixth week of life, two reproductive systems can be considered - male and female.

Towards the end of its development in the womb, a nine-month-old male fetus develops a rudiment of the uterus, the so-called "male uterus", instead of the usual prostate gland. The testicles correspond to the ovaries, the seminal vesicles to the fallopian tubes, and the clitoris is an undeveloped member.

Since ancient times, hermaphrodites have been divided into two types. The first are female hermaphrodites, that is, a manifestation of androgyny. And, accordingly, men's, the so-called ginandria.

In addition, hermaphroditism can develop according to the lateralis type, that is, the organs of the male body are on one side, and the female on the opposite side. There is also a type of transversalis, when the internal organs correspond to one type, and the external ones to another.

Despite the fact that in our society hermaphroditism is considered a pathology, it must be understood that in each of us there is a kind of double principle that is opposite to our own nature. Oddly enough, but in ancient times, hermaphroditism was very honorable. This phenomenon was sung in ballads and poems, many deities were bisexual. Therefore, one should not think that people with this pathology are worse than we are.

Treatment of hermaphroditism is strictly individual. When choosing a sex, the functional prevalence of the female or male body is taken into account. Basically, operations are performed on the external genitalia, but there are cases of operations for the complete elimination of hermaphroditism. After such operations, constant monitoring by specialists is necessary, but in general the prognosis is favorable. Unfortunately, childbearing in such a case is impossible.

Hermaphrodites are fish that have both male and female sexual characteristics. By itself, hermaphroditism is the simultaneous (or sequential) presence in a living organism of female and male sexual characteristics, as well as organs for reproduction.

There are also hermaphrodite fish that are males at the beginning of their lives, and later undergo cardinal metamorphoses of their reproductive system, turning into fully functional females. Here we are already talking about protoandric hermaphroditism. For example, representatives of the sea bass family have this form of hermaphroditism. Sea wrasses can serve as a striking example of such transformations: all males transform into females with age.

However, in the wrasse family, the reverse process is also observed: if necessary, females can also take the places of disappeared males. This happens if a male is removed from a group of wrasses. In this case, the strongest female will begin to demonstrate the behavior of a male, and after two weeks her reproductive system changes dramatically, starting to produce male germ cells.

Hermaphroditism of fish can be not only natural, but also artificial, occurring under the influence of any chemicals. So, for example, American scientists from the US Geological Survey, who studied the basins of large US rivers, came to the conclusion that mutant fish appeared in certain American rivers, which are bisexual creatures. It turned out that mutant hermaphrodites are both smallmouth and largemouth bass. Scientists have identified the main habitats of these fish: the Mississippi, Yamp, Columbia, Colorado, Pee Dee, Rio Grande, Colorado, Apalachicole rivers.

Biologists from the US State Geological Research Center are confident that this phenomenon is not related to the natural life of these fish. According to them, there is a suspicion that the hormonal restructuring of these creatures occurred under the influence of disorienting chemical signals in their body. It is worth noting that some scientists who previously claimed that these fish change their sex under the influence of various chemicals do not exclude the possibility of other factors affecting them, since some of these creatures were generally found in fairly clean water bodies.

HERMAPHRODITISM (hermaphroditismus; syn.: bisexuality, intersexism, bisexuality) - the presence in the same individual of signs of both sexes.

In Greek, the mythology of the son of Hermes and Aphrodite, the beautiful young man Hermaphrodite fell in love with the nymph of the source Salmakida; the gods heeded her passionate pleas for eternal union with him, their bodies merged into one, forming a bisexual creature.

The components that determine sex are: a set of sex chromosomes, generative elements of the gonads, the content of sex hormones in the body, secondary sexual characteristics, internal and external genitalia, psycho-sexual orientation (see Gender). In a broad sense, if any of the components of the sex of the subject does not match the rest, it can be classified as a group of hermaphrodites. In practice, hermaphrodites are called subjects with a bisexual structure of the external genitalia; all other forms of pathology of sexual development are combined into the concept of "intersex", or "intersexuality" (see Intersex).

G. is a congenital pathology, in most cases genetically determined. With quantitative or qualitative disorders in the set of chromosomes, the formation of gonads is also disrupted: they do not form at all (gonadal agenesis) or contain germinal structures of both sexes (true, gonadal, G.), being anatomically, morphologically and functionally inferior.

It is known that paramesonephric ducts are the precursors of female, mesonephric - male internal genital organs. Atrophy of the paramesonephric ducts occurs under the influence of normal embryonic testicles; in their absence or failure (dysgenesis), regardless of the presence of the ovary, the paramesonephric ducts form into the uterus, the fallopian tubes into the vaginal vaults. Thus, female internal genital organs will develop with gonadal agenesis (see Gonadal dysgenesis), testicular dysgenesis. Mesonephric ducts develop into male internal genital organs, which requires the presence of hormonally active testicles: in their absence, they atrophy (regardless of the presence of an ovary). The external genitalia undergo masculinization only under the action of a certain level of androgens in the embryo between the 12th and 20th week. embryogenesis under the condition of normal sensitivity of target tissues to them. If there is no exposure to androgens, then regardless of the genetic and gonadal sex of the embryo, the external genital organs retain a neutral (female) type of structure.

Androgen deficiency in a male embryo between the 12th and 20th week. embryogenesis or their excess in the female embryo is manifested by incomplete masculinization of the external genitalia, for example, underdevelopment of the penis and nonunion of the scrotal suture (Fig.).

Distinguish G. true (gonadal) and false (the presence of signs opposite to the gonadal sex of the subject).

True G. is a rare disease. 146 true hermaphrodites are described in the world literature [Overtsir (K. Overzier), 1961].

False G. includes all forms of testicular and extragenital (adrenal, drug, etc.) congenital pathology of sexual development, each of which has a clear clinical characteristic (see Pseudohermaphroditism).

True G., according to the literature, is characterized by the female set of sex chromosomes (46 XX), various forms of the mosaic are found; the male set of chromosomes (46 XY) is rare.

Morfol, the germinal structures of the gonads of the male (seniferous tubules) and female (follicles) sex can be grouped in one gonad (ovotestis). The second gonad may be unisexual (ovary or testis) or also bisexual. There may be a combination of an ovary on one side and a testicle on the other side.

True hermaphrodites usually have a uterus, tubes, vaginal fornix. In the presence of a testicle on one side, the uterus is formed unicornuate ("half of the uterus") from the side of the remaining ovary. Secondary sexual characteristics usually have elements of both sexes: a low timbre of voice, a mixed type of figure, more or less developed mammary glands and male-type hair.

In the vast majority of hermaphrodites of mature age, the ovarian part of the gonad functionally prevails, which is manifested by the appearance of menstruation.

In the ovarian part, yellow bodies are histologically detected, and in the testicular part, on the contrary, progressive hyalinosis of the tubules. Conception from reliably examined hermaphrodites has not been described in the literature, although the presence of a uterus and ovulation seems to indicate such a possibility.

One of important to lay down. of actions at G. operational change of a floor is. Such surgical interventions can be performed at the appropriate age, taking into account the desire and subsequent social adaptation of patients. Sex change in children 3-4 years old does not cause psychological difficulties.

At the age of 4-10 years, such a change is hard to bear, because usually at this age the consciousness of gender is firmly established, and the concept of sex in the sense of sexual function does not yet exist. Therefore, it is difficult for children to explain and justify the need for a sex change. They are sharply negative, retain their old habits and behavior for a long time after the operation (do not want to change clothes, etc.). From puberty, children begin to realize their intersexuality and become even more vulnerable. Often they themselves insist on determining the sex. At youthful age (16-17 years) this problem is complicated in connection with emergence of carefully hidden and suppressed sexual inclinations (usually heterosexual in relation to that floor, in Krom the patient was brought up).

In general, in patients aged 16-20 years, adaptation to a change from female to male is psychologically easier than when changing from male to female (features of male behavior are acquired more easily). Sex change at an older age is difficult for social reasons: most patients have acquired a certain specialty, social status, etc.

When choosing a sex, the functional prevalence (female or male part) of the gonad is taken into account. Elements of the gonad, opposite to the chosen sex, are removed, if possible, by performing a plastic surgery for the reconstruction of the external genital organs.

Mental disorders in hermaphroditism

Severe psychosis and gross intellectual decline are rare. The intellectual development of hermaphrodites usually proceeds without significant deviations from the norm, although there are isolated descriptions of hermaphrodites with deep oligophrenia (up to imbecility and idiocy). Mental immaturity (mental infantilism) of these patients with childlike behavior is more often observed.

Quite characteristic of G. is a change in personality, which, apparently, is due not only to endocrine influences, but also to the situation in which such patients find themselves. Sometimes, from early childhood, they establish characterological features due to the consciousness of "shameful inferiority." With age, such patients feel lonely and isolated from life and society. This creates fertile ground for the emergence of depressive reactions and suicidal tendencies, especially those that are situationally determined.

In general, the psyche of hermaphrodites is characterized by contact, gentleness and at the same time alertness, shyness, resentment, vulnerability, sometimes combined with hostility and outright hostility towards others.

Direct dependence between a mental warehouse and type of gonads at G. is not noted. There are cases when the mental warehouse and sexual orientation changed during the life of the same patient. An important, and sometimes decisive role in the formation of the mental warehouse of hermaphrodites is played by the conditions of education.

Psychoses that occur in hermaphrodites usually have the character of protracted depressive states, less often depressive-paranoid psychoses with delusions of attitude and persecution.

Treatment of severe mental disorders in patients with G. does not have any differences compared with the treatment of other mentally ill patients: antidepressants, "large" and "small" tranquilizers are used. In the correction of personality changes, medical and pedagogical influences are especially important.

Forensic medical significance of hermaphroditism

G.'s examination represents one of types court. - medical. studies of controversial sexual conditions (see. Sexual conditions are controversial). This examination is carried out by order of the bodies of inquiry, investigation and court. The reason for the examination of G. are the following cases: determination of fitness for military service, admission to special educational institutions, obtaining identity documents, investigating cases of insults and sexual crimes. G.'s examination may be appointed in connection with the consideration of claims for alimony, divorce (for example, if normal sexual intercourse is impossible, there is no ability to conceive or fertilize).

At court.-med. examination for G., the sex of the subject is established on the basis of complex studies: a thorough collection of a specific anamnesis, a general examination of the body, anthropometric measurements, determination of the nature and severity of secondary sexual characteristics, examination of the external genital organs, establishing the presence of the gonads and their functional manifestations.

When collecting an anamnesis, it is necessary to identify the opinion of the subject about his gender, the characteristics of sexual desires and their manifestations, to establish the age, in which secondary sexual characteristics were revealed, and sexual function. Deviations in sexual desire can also be associated with sexual perversions (see).

During a general examination of the person being examined, attention is paid to the general appearance and size of body parts, the shape and size of the pelvis, the nature and deviations in the state of secondary sexual characteristics (facial and body hair, development of the mammary glands, voice timbre, etc.). However, the data of such an examination cannot in itself serve as a basis for resolving the issue of gender.

When examining the external genital organs, their structure and the ratio of individual parts (topographically and in size) are noted. The predominance of the male or female type of structure of the external genital organs (without taking into account their functional manifestations) also cannot serve as a basis for establishing sex. It should be borne in mind that there may be independently existing malformations of the external genital organs. Discharge from the genital organs is of diagnostic value: seminal fluid or menstrual flow. The absence of seminal fluid does not exclude the presence of testicles, since they may be underdeveloped or their secret due to malformations may not come from the genitals. Males may have pseudomenstrual discharge, which, however, does not have a certain cyclicity; at the same time, in females, menstruation may be absent due to age, hormonal changes, diseases, etc. Therefore, laboratory tests are carried out to establish the true nature of discharge from the genital organs.

Honey. documents on treatment by urologists, obstetrician-gynecologists, on pregnancies, childbirth, abortions also contribute to the solution of the issue of sex and sexual functions.

If necessary, repeated and commission surveys, stationary observations are carried out. In a hospital, laboratory studies of secretions, hormonal studies, and in exceptional cases (with the obligatory consent of the subject) are done, and a biopsy of tissues and punctate of the sex glands. At court.-med. examination of the corpse of a hermaphrodite, it is necessary to conduct appropriate microscopic studies.

Quite often simultaneously with sex determination at false G. the question on ability at male hermaphrodites to fertilization is resolved (see) or at female hermaphrodites to conception (see).

hermaphroditism in animals

Most invertebrates are dioecious, but there are hermaphrodites in each type. G. is sometimes characteristic of whole types of invertebrates: sponges, flatworms. At the same time, among the flukes, the genus Schistosomum should be indicated as a representative of the dioecious, and within the types of mollusks and annelids, both G. and dioeciousness are equally common.

Among vertebrates, both regular G. and pathological G. are found. Regular G. is known only in bony fish.

There are two forms of regular G. in fish: functional, or synchronous (functioning gonads simultaneously contain both mature eggs and sperm; self-fertilization, as a rule, does not occur, although it is possible), and non-functional (parts of the gonad do not function simultaneously, that is, they do not function simultaneously). the ovaries develop before the testes or vice versa; such individuals may begin to function as females, then the ovary is reduced, the oocytes are resorbed and the testis functions). In typically dioecious fish, pathological G. has been described, which is found among sturgeons, rainbow trout, carp, herring, coho salmon, sardines, and others; in some cases, the male and female gonads are equally developed, in others, the gonads of one of the sexes predominate.

In more highly developed vertebrates, natural hypertrophy does not occur, but there is no such group of vertebrates where the phenomenon of pathological hypertrophy is not observed.

Pathological G. in higher vertebrates can be caused by two reasons. The first is the presence of a mosaic set of chromosomes in somatic cells, which determines the development of certain sexual characteristics (female or male) in different parts of the body. For example, in chickens and some songbirds, one half of the body is typically male and the other is female. This phenomenon is more pronounced in insects (see Gynandromorphism). The second reason is the effect on the developing embryo of hormones of the opposite sex, which leads to the development of G., regardless of the genetic constitution of body parts.

Biol, the meaning of G. in animals is clear in some cases. For example, self-fertilization in tapeworms in the human intestine is important for the survival of the species, since only one individual often lives in the host organism.

G.'s studying at animals helps to open endocrine mechanisms of regulation of a floor. In practice, these mechanisms are used to regulate sex in page - x. animals. Through exposure to various it is possible to obtain in a number of animals a sex reversion up to the ability of the modified individuals to form germ cells of the opposite sex. Thus, hormonal treatment of chicken eggs for incubation makes it possible to turn males into females, but only at the embryonic stage, because with the development of the genotype in chickens, a complete reverse reversion to the male sex is observed. And at last, on experimental G.'s model at animals test (testing) of hormonal preparations is carried out.

Bibliography: Golubeva I.V. Intersex adaptation to sex change, Journe, neuropath. and psychiat., vol. 70, c. 6, p. 911, 1970, bibliogr.; Lieberman LL Congenital disorders of sexual development, L., 1966, bibliogr.; Savchenko H. E. Hypospadias and hermaphroditism, Minsk, 1974, bibliogr.; With t and r to about in a H. T. Fundamentals of clinical andrology, M., 1973; Teter E. Hormonal disorders in men and women, trans. from Polish, Warsaw, 1968; B o s z k o w s k i K. Inter-seksualizm, Warszawa, 1970, bibliogr.; G u i n e t P. L'hermaphrodism vrai, Ann., Endocr. (Paris), t. 26, p. 37, 1965, bibliogr.; Kraatz H. u. Fischer W. Gyna-kologisch-urologische Operationen, S. 135, Lpz., 1972.

I. B. Golubeva; E. 3. Bronstein (judicial), D. D. Orlovskaya (psych.), D. V. Ponov (biol.).

There are boys, girls and others

Imagine a situation. You have just given birth to a long-awaited baby. And even if during the ultrasound you were told that it was a boy, you still ask the midwife the traditional question: “Who?” And in response, silence. And then confused: “We don’t know ... Something is wrong with the child’s genitals.”
Instead of joy, you have shock. What to say to relatives and friends who cut off the phone, wanting to congratulate? Did the queen give birth on the night of either a son or a daughter? You lie at the bottom for five days, until the doctors conduct a study and determine the sex of the child. The diagnosis sounds like a sentence: hermaphroditism.
And the second shock parents experience when they find out that a child will need lifelong hormone therapy.

But is the situation as tragic as it seems at first glance? Can such children normally exist among their own kind? What types of treatment does modern medicine offer them? And most importantly, who is to blame? What is the reason for the incorrect formation of sex in the fetus? The search for truth turned into a real investigation, in which gynecologists, surgeons, urologists, ultrasound doctors, and pediatricians helped me. But the main expert was Natalya Kalinchenko, a pediatric endocrinologist at the Endocrinological Research Center of the Russian Academy of Medical Sciences, PhD.

- Currently, the term "hermaphroditism" is being phased out and replaced by the wording "diseases associated with impaired sex formation." This is because "hermaphroditism" sounds offensive to patients, like a stigma. Therefore, now in the diagnosis we write "violation of the formation of sex."
- On the Internet there is such a decoding of hermaphroditism: this is the presence of male and female sexual characteristics in an individual. Right?
- Generally true. Violation of sex formation (SFP) is divided into three types:
1. Violation of the formation of sex 46, XX (what used to be called female hermaphroditism). The patient has a female karyotype (female genetics) - 46, XX, but the external genitalia have a male structure or an irregular structure closer to the male.
2. NFP 46, XY (male hermaphroditism). A patient with a karyotype of 46, XY, is genetically a boy, he has male gonads (testicles), and the external genitalia are female in structure.
3. True hermaphroditism, or ovotesticular, is exactly what your question refers to: the patient has both female and male genital gonads (testicles and ovaries). In principle, NPP is any abnormal structure of the genitals.

Our reference.
According to the internal structure, there are three types of NFP - bilateral, unilateral and mixed. Unilateral - this is when the ovary or testicle is located on one side, and on the other side there are mixed gonads (both testicle and ovary). Bilateral - when in a patient on both sides the gonad is represented by the tissues of both the testicle and the ovary. A mixed structure is characterized by the presence of a testicle and an ovary in the same tissue. And sometimes it happens that the gonad is completely absent, and instead of it there is a connective tissue tie.

- It often happens that because of the underformed external genitalia, the doctor cannot even clearly say who it was born - a girl or a boy. And how to be in that case?
– Do karyotyping and ultrasound of internal organs. Ultrasound will immediately show if there is a uterus, gonads. And this will help determine the type of NPP - male or female. And then there is a hormonal and genetic examination. Most often, a violation of the formation of sex occurs in boys: genetically he is a boy, and the external genitalia are incorrect. The development of male genital organs is under the influence of testosterone: in order for the boy's genitals to form correctly, a high level of this hormone is needed. By the way, in a male fetus, testosterone levels in utero are almost as high as in adolescents. It decreases only after the birth of a child. And this intrauterine period is very important.
As for girls, the laying and formation of the external genital organs according to the female type proceeds indifferently, that is, if the fetus has no gonads (internal genital organs) at all - inside it is asexual, then a child will be born with a female structure of the external genitalia, and outwardly it will be a girl.

Important.
Do you know what a low testosterone level is fraught with for a boy in the womb? Hypospadias - an abnormal structure of the penis (testicles do not suffer). This disease also belongs to NPP. With a mild degree of hypospadias, the opening of the urinary canal opens at the edge or in the middle of the head - a purely urological problem. The cause may be external factors, for example, toxicosis in the mother or viral infections in the first trimester of pregnancy.
In a severe form, the urethra opens either in the middle or at the base of the penis or even on the scrotum, and the penis is most often curved. An examination of such a defect should no longer be carried out by a urologist, but by an endocrinologist. Some forms of severe hypospadias are inherited. Usually, in a year or two, boys undergo surgery. Hypospadias is a fairly common disease, one in 150 to 180 people. In recent years, there has been an increase in the growth of hypospadias. It is believed that one of the reasons is the deterioration of the environment. There are entire regions in third world countries where most boys are born with hypospadias. When the study was done, it turned out that pregnant women worked in the fields, which are treated with chemicals that are similar in structure to estrogen (female sex hormones), as a result of which testosterone production in the embryos was blocked.

What forms of NPP are the most common?
– Congenital dysfunction of the adrenal cortex (VDKN), or adrenogenital syndrome (AGS). This disease is due to the fact that the adrenal glands do not produce the enzyme that is responsible for the biosynthesis of the hormone cortisol. With this form of AGS, the production of hormones responsible for maintaining blood sugar and salt in the body is disrupted. To get the adrenal glands to somehow produce these hormones, the body forces the adrenal glands to work actively. As a result, they try their best, increase in size, but the only thing they are capable of is to produce androgens in excess. As a result, a girl is born with an irregular structure of the genitals.

Our reference.
The adrenal glands produce three types of hormones:
mineralcorticoids (aldosterone) are responsible for maintaining the right level of salt in the body;
glucocorticoids (cortisol) regulate blood circulation, maintain blood sugar levels and help the body cope with stress - infections and injuries;
androgens (male sex hormones) are produced in both sexes. Responsible in boys and girls for the appearance of hair growth during puberty.

- What is the reason for the VDKN?
“It's a hereditary disease. In the parents of a sick child, one chromosome contains a damaged gene, and the other contains a healthy one. Such parents are called "healthy carriers". If the paternal chromosome with the defective gene joins with the maternal chromosome with the defective gene, they will form a pair of chromosomes with two abnormal genes, which will make the child sick. If the father's defective chromosome fuses with the mother's normal chromosome (or vice versa), the child will be a healthy carrier, just like the parents. When two normal chromosomes fuse, the child will be born healthy. That is, out of four children born from two healthy carriers, one child will be absolutely healthy, two will be "healthy carriers" and one will be sick with HCHD.

Probability theory.
If the parents are carriers, the risk of having an affected child is 1:4 for each subsequent pregnancy. But if the family already has a sick child, this does not mean that three children from subsequent pregnancies will be healthy.

- If we assume that a child with HCHD has grown up and his partner is healthy, what will their children be like?
- The pathological gene is compensated by the normal one, and all children from this marriage will be healthy carriers. The probability of meeting two healthy carriers is 1:50. The risk increases significantly with consanguineous marriages of cousins, second cousins ​​and sisters. For children from the marriage of a person suffering from CVD and a healthy carrier, the risk increases to 1:2. I must say that VDKN is a fairly common disease. 1 in 10,000 newborns may be sick. That is, for every 125,000 children born per year, there are 20 patients. And if they are not diagnosed in time, they will die in the first 15-20 days of life from adrenal insufficiency: they eat poorly, they vomit, they lose weight. That is why, since 2006, our country has adopted a law on the introduction of neonatal screening for VDKN. On the 4th day of life, blood is taken from each child from the heel and five frequent and serious diseases are diagnosed at once, which must be treated immediately after birth. The diagnosis of VDKN is confirmed as early as 2 to 3 weeks after birth.

memo
Hermaphrodite - this is a person who has a discrepancy between the structure of the gonads and genital organs or secondary sexual characteristics.

- Do they perform fetal diagnostics? After all, this would certainly make it possible to treat a child with VDKN in utero.
– Now in families where there is already a child with CHD, parents are advised to conduct prenatal diagnosis. At the 10th week of pregnancy, tissue is taken from a woman through the cervix (chorionic villus biopsy) to determine the sex of the child, as well as for the presence or absence of VDKN.

From a journalist's diary.
A familiar gynecologist said that for many years of practice he had only once had a case when, during an ultrasound scan, he discovered an abnormal structure of the genitals in the fetus. Rather, at first he simply suspected a defect and did not let the pregnant woman go for more than an hour until he carefully examined the child. But which of the diagnosticians, especially in antenatal clinics, where kilometer-long queues of pregnant women line up, will examine some genitals for an hour? The heart is working, the legs and arms are intact, the head is in order - and forward.
Now I’m calling like crazy to all my pregnant girlfriends and campaigning for paid ultrasounds from highly qualified specialists: “Demand proof that your children are not hermaphrodites!” I scare them with ominous statistics.
“And what will happen to a child who is not a boy, not a girl? Chao, baby? Abortion?" I tortured my obstetrician-gynecologist friend.
“If the fetus is female, the mother will be given a steroid drug to prevent masculinization of the external genitalia. The woman will have to take hormones until the results of the chorionic villus biopsy are ready. If it turns out that the fetus is healthy, steroids can be discontinued.
“And the hormones during this time will not harm the child? Why poison the baby in vain? - I did not let up.
“No, this is too short a period for the medicine to have a negative effect on the development of the fetus,” the friend reassured. – If the fetus is male and has CVD, steroid treatment is also stopped. But if the fetus with HCHD is a girl, then the mother will have to take steroid drugs throughout the pregnancy. This will help not only to reduce the masculinization of the external genital organs, but also in the future, after birth, will reduce the volume of plastic surgery to correct the genitals. The only one who can be adversely affected by hormone therapy is the mother. Its complications are reduced to weight gain and increased formation of stretch marks on the skin.
Well, they will do an operation in early childhood, and then? What awaits such children?
“With proper and timely treatment, you can expect normal dates for the onset and course of puberty,” the friend continued. - In some cases, there is a late onset of menstruation and ovarian dysfunction. Girls with CHD have a normal uterus and ovaries. In boys with CHD, subject to compensation for the disease, the reproductive function is not impaired. Now, I hope you understand why early diagnosis and treatment is so important?

Our reference.
Masculinization - masculinity, strengthening of male characteristics in a woman's body. During puberty, masculinization in girls leads to the development of secondary male sexual characteristics, an increase in the clitoris, depression of menstrual function, underdevelopment of the mammary glands and uterus, hirsutism, and loss of femininity. As a rule, masculinization in women is accompanied by an increase in libido (in rare cases, it reaches a pathological increase - nymphomania. Read about this disease on the website of our journal).
Likbez
Primary sexual characteristics - These are the external and internal genital organs (genitals).
In a girl: small and large labia, uterus, ovaries.
In a boy: penis, testicles.
Differentiation of primary sexual characteristics begins from the 7th week of embryonic development.
secondary sexual characteristics appear during puberty. In girls from the age of 8, the mammary glands increase, pubic and axillary hair appears. In boys, from the age of 9, hair growth and an increase in the external genital organs begin.
Each organism is characterized by a specific set of chromosomes called karyotype . The human karyotype consists of 46 chromosomes - 22 pairs of autosomes and two sex chromosomes. In a woman, these are two X chromosomes (karyotype: 46, XX), and in men, one X chromosome and the other is Y (karyotype: 46, XY). Each chromosome contains the genes responsible for heredity. The study of the karyotype is carried out using cytogenetic and molecular cytogenetic methods.
Karyotyping - a cytogenetic method that allows you to identify abnormalities in the structure and number of chromosomes that can cause infertility, other hereditary diseases and the birth of a sick child.

- Does it happen that obstetricians skip NFP in the maternity hospital?
- It happens. It is precisely in the maternity hospital that they most often miss the situation when initially the development of the female type is indifferent. For example, a genetic boy is born with a purely female phenotype (female structure of the external genitalia). Outwardly, this is a girl, so obstetricians in full confidence declare to the woman in labor that she has a daughter. Until the age of 14-15, she grows quietly, and no one, including herself, suspects anything. And then her parents bring her to us with a complaint about the lack of secondary sexual characteristics: the mammary glands do not grow, there are no periods. We're doing a test, and the ultrasound shows that the girl doesn't have a uterus. We take blood for hormones, and the analysis shows that there are no estrogens, as if the ovaries are absent. To finally clarify the picture, we must make a karyotype, and then a revelation awaits everyone: the girl has a karyotype of 46, XY, that is, genetically she is a boy.

- Can't a mother understand for 14 years that her daughter is not like everyone else?
- If a child was born with a purely female structure of the genitals, it is almost impossible to determine that she is a boy, because outwardly it is not noticeable.

From a journalist's diary.
Now, if ultrasound of the small pelvis were done to all children without fail, then it would be another matter. And why doesn’t such an idea come to the officials of the Ministry of Health? And then as it happens in practice: the genetic sex is detected only when the child is admitted to the hospital for surgery.

- And what is the psychological portrait of such girls? Is it a sign of genetic sex that the daughter behaves like a boy: plays boyish games, for example?
- Clear behavioral signs that prove in children belonging to one sex or another have not been fully studied. Today, psychologists see that there is a difference, but so far it is at the research stage, especially in young children.

Our reference.
It is believed that before puberty, the psychological development of boys and girls is basically the same.

What would you advise mothers to pay attention to?
- On clitoral hypertrophy in girls. Normally, it should be covered by the labia if the girl was born full-term. If the clitoris protrudes beyond the labia majora, then this is a signal that the child should be shown to a pediatric endocrinologist. In a boy, attention should be paid to the presence of testicles in the scrotum. Mom can carefully probe them herself or ask a doctor about it. Until now, boys of 9-10 years old with an empty scrotum come to see me.

From a journalist's diary.
Previously, among doctors it was even considered indecent to touch a boy's penis and scrotum. 10 years ago, when I took my five-year-old son to the clinic, the doctor simply examined him visually - that's all.
I call a pediatrician I know, I ask an idiotic question: “How to distinguish a boy from a girl?”
“As for boys with NPD, it is easier with them, because their genitals are outside and you can immediately see that, for example, the scrotum is split or the penis is curved,” she explains. “But there is a big problem with girls: none of the parents know how they should be normal.”
There are complex forms of VDKN, when the girl's body produces male sex hormones in excess and she is born with a purely male structure of the genitals, that is, she has a normal penis, a normal scrotum, however, there are no testicles in it. Even without bothering to do an ultrasound, a lazy pediatrician can diagnose bilateral cryptorchidism and tell him to wait up to a year until the testicles themselves descend into the scrotum. In Moscow, such mistakes are almost never made, but in the regions, especially in the far corners of the country, where medicine is poorly developed, there are still such cases.

Today, it is customary to call a hermaphrodite a person who has both female and male genital organs. Such a definition can, in principle, be considered correct, but it is by no means the only one. Therefore, below we will talk about who a hermaphrodite is and why he got such a name.

Hermaphrodite in mythology

The word hermaphrodite appeared in Greek mythology. That was the name of one of the characters, who was the son of the god Hermes and the goddess Aphrodite.

This young man, at the age of 15, went to travel the world and, bathing in the spring of the nymph Salakis, fell in love with her. Their feelings were mutual, and the nymph persuaded the gods to unite their destinies forever. So their bodies and souls merged into one. Since then, a legend has appeared that every person who has bathed in this source at least once, himself became a hermaphrodite, if not in physical terms, then in moral terms for sure. And since then it has become customary to call all living simultaneously bisexual creatures by the name Hermaphrodite.

Who is a hermaphrodite today

Today, a hermaphrodite is commonly called a creature that has both male and female sexual characteristics. Most often, this is the name of a person who is a bisexual creature. This structure of the human body is abnormal and is quite rare. It is a consequence of disruption of the hormonal system and the work of DNA chains in the body. Abnormal hermaphroditism occurs not only in humans, but also in developed animals, such as monkeys.

Moreover, such hermaphroditism can be of two types:

1. True. It is characterized by the presence of the genital organs of men and women at the same time. In such a situation, as a rule, only one genitals are left at the request of the patient.
2. False. In this case, there is a significant contradiction between gender (external signs) and the psychological perception of one's self (internal signs). That is, a man feels like a woman and vice versa. In this case, either long-term psychiatric treatment or a sex change is required.

What is a hermaphrodite in the natural world

Even at school, in biology lessons, we were told about dioecious, polyoecious and monoecious plants. So, monoecious plants are natural hermaphrodites. But not only plants can be hermaphrodites, they are also some types of fish, coelenterates, crustaceans and even insects.

By creating such natural hermaphrodites, nature made sure that these species could create their offspring on their own.

True hermaphroditism is a condition that combines in the human body both the male testicle and the female egg or gonads, which have histological features of both sexes (ovotestis). Often, hermaphroditism concerns only the abnormal formation of the external genital organs, but there are incidents when the syndrome also affects the internal organs (very rarely).

In the initial stages of embryonic development, it is still difficult to determine the delimitation of the genitals. This is due to the fact that initially in its structure the gonad is bisexual. Only at a later stage do differences begin to form in the rudiment of the gonad. But there are also options when bisexual development occurs at more late stages, that is, the baby comes into the world with heterogeneous signs of one and the other sex.

Classification of true hermaphroditism

The severity of the deviation may also vary. Therefore, it is customary to divide true hermaphroditism into two types:

• there are anomalies of external organs on the body (in addition to male genital organs, there are also female ones, an insufficient set of organs of one of the sexes, a complete set of female and male genital organs);
• there are no anomalies of external organs on the body (secondary male (female) sexual characteristics, or both sexes).

Classification of true hermaphroditism:

1. differentiation of the genital organs to the female side, which leads to the formation of a separate mouth for the urinary perineal tract, clitoral hypertrophy, a well-formed separate entrance to the vagina;
2. the site of the rudeminary urogenital sinus has a separate entrance to the vagina and a separate opening for the urethra, the clitoris is identical to the shape of the penis, that is, it is hypertrophied;
3. the cavity of the urethra of the urethra in the vagina is high, may form, in rare cases the prostate gland is remarkable;
4. a set of genital organs, both male and female. A man who has a full set of genital organs also has mammary glands, uterus and vagina, and a woman has a prostate, scrotum and penis.

People suffering from true hermaphroditism, who do not have any external deviations of the genital organs, as well as secondary genital organs, combine male and female genital organs, and also have gonadal tissue. It is difficult to diagnose hermaphroditism with this outcome.

There are such deviations of the gonads with true hermaphroditism:

1. one or two testicles of the gonad, the same number of ovaries;
2. the number of gonads (one or two) is arranged according to the type of ovotestis;
3. the mosaic structure of the gonads, that is, the tissues of the testicle in the gonad are intertwined mosaically.

Causes of true hermaphroditism

Work on the cause of the appearance of this disease in patients has shown that there may be an unrecognized mosaicism, which manifests itself when examining a particular area of ​​body tissues. There are cases when true hermaphroditism has become a hereditary (family) disease. It can also be affected by non-genetic exogenous factors that affect testicular tissue. A man with a 46XY chromosome field is subject to hermaphroditism, which accompanies scroto-perineal hypospadias, with or without the presence of a genitourinary sinus. In women with 46 XX chromosome field, hermaphroditism is present with or without a urogenital sinus.

Quite rarely, true hermaphroditism occurs with a mosaic chromosomal arrangement (XX ∕ XY; XX ∕ XXYY; XX ∕ XXY). Sometimes there are incidents when a double fertilization of the egg occurs (the phenomenon of chimerism), which can cause the formation of bisexual gonads. Chromosome mutation can also cause hermaphroditism.

So, we can conclude that the causes of the disease are not fully disclosed and additional surveys are now being conducted on this issue.

Symptoms of true hermaphroditism

In some cases of true hermaphroditism, patients suffered from sexual, mental and psychological abnormalities. The clinic of true hermaphroditism manifests itself on the external genital organs and is directly determined by one and the other sex by the gonad, its development and functions. Several signs of a combination of ovarian and testicular tissue may develop. The reproductive organs may be a combination of ovarian and testicular tissue, which is called ovotestis. The magnitude of the formation of ovotestis can be modified, then mature follicles can appear in the ovaries, respectively, in the testicles - the initial stages of spermatogenesis.

External signs of true hermaphroditism

As for external signs, it can be:

• the presence of a small size of the penis;
• in the absence of gonads, folds are formed that may resemble the labia or the scrotum;
• the vagina in patients is often quite well developed and opens into the back of the urethra;
• clitoral hypertrophy is found, so the genitals are more similar to female ones.

Often, patients may experience pain when bleeding from the urethra or vagina. Analysis of androgens and estrogens may be within the normal range.

Deviations in the process of puberty

During puberty, feminization and virilization, menstruation, etc., may occur. In the form of cyclic hematuria, menstruation occurs in individuals of the male phenotype.

Many times it is the malformations of the reproductive system in humans that are combined with the abnormal development of the genitals and their deviations from the norm.

Diagnosis of true hermaphroditism

It is possible to diagnose true hermaphroditism in a person if there are clearly expressed indefinite or dual nature of the genitals. In such cases, it is worth contacting only highly qualified specialists, since your recovery and your further ability to produce offspring directly depend on this.

Tests performed to determine true hermaphroditism

1. To determine the genetic sex, specialists do karyotyping, which will help to study the composition and number of chromosomes;
2. Before ultrasound diagnosis of the small pelvis and abdominal cavity, which can recognize various deviations and defects from the genital organs, the doctor usually conducts a visual examination, palpates the genital area;
3. A blood and urine test will help determine the amount of pituitary, sex, adrenal and other hormones;
4. The final result and diagnosis can only be determined by laparotomy or histological examination of the genital internal organs.

It is imperative to distinguish between true hermaphroditism and false male hermaphroditism (with this outcome, there are no ovaries, only testicular tissue is present), as well as with false female hermaphroditism (caused by virilizing hyperplasia of the adrenal cortex, while they are sharply multiplied by the excretion of 17-ketosteroids). When consulting, the doctor may ask you about important factors that affect the development of the disease: successful (or not successful) bearing of the child during pregnancy, whether the mother's body was exposed to any medications, infections, any complications; whether any anomalies of the genitals of the baby were found, for example, the incorrect position of the testicles in the scrotum, etc.; did puberty correspond to age norms; whether there is a violation of normal sexual life, activity. To be convinced of the accuracy of the diagnosis, it is worth having an endocrinologist, a urologist and a geneticist.

Prevention of true hermaphroditism is a regular visit to a urologist (once a year).

Treatment of true hermaphroditism

The treatment for true hermaphroditism is hormonal therapy. To do this, you need to know the cause of this disorder. Hormones used: thyroid glucocorticoids, etc.

If necessary, doctors make prompt correction of dysfunction of the genital organs. The patient has the right to choose his gender.

In order not to be at risk of malignant degeneration of underdeveloped testicles, they are also removed.

For women, an additional estrogen therapy is prescribed, which gives this individual femininity. After that, it is necessary to visit a psychologist for the correct formation of ideas about the current sexual behavior and your gender.

Prognosis of true hermaphroditism

Patients suffering from true hermaphroditism, who were raised as women with a karyotype of 46,XX, can become pregnant and, moreover, it is absolutely normal to bear and give birth to a child. For men, the results are not so comforting, because only a small number of them become parents.

History describes cases when a man had two children, and an ovotestis was removed from a person of a female phenotype. Sometimes true hermaphroditism can remain invisible until old age, if you do not take into account the problem of infertility or some complaints about the lower abdominal cavity.

For normal human life, no threats arise from the disease, people with such a diagnosis can live quite fully. Only the fact that few people can give offspring, or rather, very few, remains disappointing, because the consequence of the disease is infertility.

With such an ailment, all kinds of sexual perversions are observed, such as homosexuality, transsexualism, etc.

Depending on the psychological and physiological orientations, as well as anatomical characteristics, the place of the patient in society is determined, but most often these are maladjusted individuals.

Is it hard to be both a man and a woman at the same time?

18-year-old Muscovite Anya is a prominent girl in all respects. Athlete, student, beauty. The attention of the strong half, of course, is not deprived and is even going to get married. So, on the eve of the wedding, Anyuta suddenly found out that she was not a girl at all. And not a woman at all, but ... a man! How Moscow doctors helped Anya and why there are more hermaphrodites in Russia, “MK” was told by the doctor of medical sciences, head. Department of Uroandrology of the SCCH RAMS Sergey YATSYK.

- Sergey Pavlovich, do we have a pandemic of hermaphroditism?

- I would not exaggerate so much. In general, this disease has been known since ancient times. I think it has been around since the beginning of mankind. But indeed, the number of hermaphrodites has recently increased. This is a fact, and you can't get away from it. The main reason is environmental problems, radiation background ... Plus, a lot of new airborne diseases have appeared that women get sick during pregnancy. All these factors act at the genetic level, and as a result, hermaphrodite children are increasingly being born even to seemingly healthy parents.

- And how many of them are there in Moscow?

- No one keeps accurate statistics. Yes, and the problem is too intimate, many do not seek help from doctors. But now more than fifty patients from among children and adolescents pass through my hands every year. By the way, true hermaphroditism (when there are male and female gonads) is very rare today. More often it is false. We call the patients suffering from it “mosaic people”. They have a ratio of male and female is not 50 to 50, but 30 to 70 or 60 to 40.

“Is it true that androgynes are easy to spot in a crowd?”

- Nothing like this. Having met such a person on the street, we may not even guess that he has an intimate problem. By the way, some are convinced that hermaphrodites are mentally retarded, but this is not at all the case, they are completely normal mentally developed. There are many intellectuals and talents among my patients. If a hermaphrodite has more or less adapted in one field, then it can have sex and generally lead a normal life. The whole problem is just in this adaptation. And it will be very difficult if, immediately after the birth, the parents do not determine who will grow up with them - a boy or a girl. And the impetus for their choice should be the correct diagnosis.

- And often doctors do not determine hermaphroditism in babies?

- Alas, yes. Especially if the external genitalia are not greatly changed. This was the case with our patient Anya, who came to us because she did not have a period. All organs were formed according to the female type, so she was brought up as a girl. Buy dolls, dress up in dresses. And she has male testicles, and male hormones. How to be? Anya herself, as I understood from a conversation with her, does not imagine herself in the role of a man. We performed an operation on her and removed the male gonads in the inguinal canals. Moreover, the incision was made specifically above the pubis, so that Anya could tell her chosen one that she had gynecological problems and because of them she could not have children. Then they decided together that they would adopt a child. Everyone is happy!

In general, when a baby is born with hermaphroditism, it is important to understand the karyotype. And then you need to conduct an ultrasound examination, take tests for hormones. And in the future, taking into account all these parameters, parents must make a decision. Otherwise, it can be like this: the child has both male and female genital organs, mom and dad believe that it is better to remove a tiny penis, considering it a rudiment, and raise the child as a girl. And then it turns out that the karyotype is male. It turned out that the gender was determined incorrectly.

We recently brought in a 12 year old girl. With pigtails, earrings. It turned out to be a hermaphrodite. Broad shoulders, narrow pelvis - all of the male type. But I talked with my mother and realized that the patient can only be adapted in the female field - she presents herself only as a girl. Yes, and it is difficult to change gender: you will have to move to a new place of residence so that you have new friends, a new school, etc. Therefore, we “corrected” the mistake of nature, and with the help of hormone therapy, the patient became a real girl.

- Medicine in the treatment of hermaphroditism has gone far?

- If we talk about surgical methods, then certainly. Today you can do such a cosmetic operation that no one will even guess about a person’s illness. Well, the latest generation of hormonal drugs allow you to control the body so much that it takes on the desired feminine or masculine proportions. So, if immediately after birth the karyotype is correctly determined, an operation is performed (if necessary), the child will grow up absolutely normal. The only thing is that such a person will probably not have children. Hermaphrodites are sterile.

- Can't modern technology help them?

- If you are talking about IVF, then it helps hermaphrodites only in exceptional cases. For example, you can try when the patient's gonads produce at least a few sperm. But usually even these single spermatozoa are not viable or defective.

- Does it often happen that a hermaphrodite, who was correctly identified by a karyotype and raised, for example, as a man, then at some point decided to “change orientation” himself and declared himself a woman?

- Oddly enough, this is a rarity. Usually, if a hermaphrodite is socially adapted, he does not have such throwing. But on the other hand, if social adaptation was wrong, then even a normal person can eventually become a homosexual or a transsexual. We have examined such patients more than once, and it turned out that they are absolutely healthy (hormones, internal genital organs and glands - everything works perfectly).

- Is it planned to examine every newborn in Russia for hermaphroditism?

- In Europe, they have been doing this for a long time as part of research on genetic anomalies. In our country, in theory, every child at the age of one month should have an ultrasound scan of all internal organs. But, alas, in many regional clinics this requirement is neglected and they risk missing the moment - not identifying a hermaphrodite. However, ultrasound does not always cope with this task. Here you need a study that allows you to unambiguously determine the change in the genotype. And this is an expensive thing.

- Or maybe check for hermaphroditism, for example, all Moscow schoolchildren?

- I do not think that there is such a need. Enough medical examination during puberty. It is also planned to create a reproductive health passport. It will be filled in parallel with the polyclinic card. And all the features of the development of the genital organs will be entered into it, starting from infancy.

- How can parents avoid the appearance of a hermaphrodite child?

- They need to undergo genetic testing for compatibility. This factor is of great importance. But even if the geneticist does not notice any danger, nature can still surprise.

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In Greek mythology, Hermaphrodite was the son of Hermes and Aphrodite. The legend tells that one of the nymphs, seeing him naked, fell in love with no memory. Unable to charm Hermaphrodite, she prayed to the gods to unite their bodies forever. The prayer was heard, and an androgynous creature appeared in the world.

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Only one extraordinary case is reliably known, when a human being was capable of normal sexual relations with both a man and a woman. A 28-year-old prostitute had a 14 cm long penis and an 8.5 cm vagina. She had both ovaries and testicles, both menstruation and ejaculation.

Hermaphroditism is a congenital abnormal structure of the external genitalia that makes it difficult to determine the sex of the child.

There are false male, false female and true hermaphroditism. In addition, hermaphroditism is a symptom of various congenital diseases of the reproductive system in terms of etiology, pathogenesis, and clinic.

The frequency of occurrence is 1:1700-1:2500 newborns.

Etiopathogenesis. The differentiation of the external genital organs depends solely on the presence of androgens and occurs in the period from the 6th to the 16th week of gestation. Differentiation of the external genitalia according to the male type is determined by an adequate level of androgens. The division of the urogenital sinus into the urethra and vagina without further differentiation is due to the absence of androgens. The differentiation of the gonads into testicles or ovaries depends on the presence of the Y chromosome and is determined directly by the presence of the H-Y antigen, the HLA antigen found on the surface of all male cells. When the gonads differentiate into the testicles, they produce and secrete testosterone, which is a precursor of dihydrotestosterone, a powerful androgenic hormone involved in sex differentiation. Thus, the occurrence of metabolic or growth disorders at any stage of this process can lead to inadequate androgen production and incomplete sexual differentiation or false hermaphroditism in boys.

Excess androgen production in girls mimics the effects of testosterone and dihydrotestosterone in boys, in part causing clitoral enlargement, incomplete union of the labia, and incomplete separation of the urethra and vagina. At the same time, excessive production of androgens in the fetus may be due to increased synthesis of androgens in the adrenal glands or ovaries of the mother or the introduction of androgens during hormone therapy.

The most common cause of increased androgen production in the fetus is congenital adrenal hyperplasia, due to a deficiency of 21-hydroxylase (most often) involved in the synthesis of cortisol and, less commonly, a deficiency of 3-(β)-hydroxysteroid dehydrogenase or 11-hydroxylase.

Clinic. The incorrect structure of the external genitalia is diagnosed immediately after birth.

Clinical manifestations:

The impossibility of determining the sex after examining the external genital organs;

With a small size of the penis (the length of the penis measured from the pubic joint to the tip of the head is less than 2.0 cm) in an "obvious boy";

The location of the gonads (testicles) in the labia of the "obvious girl";

With splitting of the penis and scrotum in combination with bladder exstrophy.

Usually, difficulties with sex determination occur in the most severe forms of hypospadias.

Diagnostics.

A. The diagnosis is not in doubt, since immediately after the birth of the child during the initial examination, an abnormal structure of the external genitalia is revealed. Difficulties in diagnosis are due to determining the sex of the child. In matters of gender identification, the joint supervision of a neonatologist, endocrinologist and geneticist is mandatory.

B. First of all, to select the sex, it is necessary to determine the sex chromatin on the 3-5th day of life (a smear from the buccal mucosa to determine heterochromatin (Bar bodies).

1. With careful monitoring, most newborns will be 3% or more chromatin positive (any adult woman should be 15-30% chromatin positive). In chromatin-positive newborns, false female hermaphroditism is diagnosed, due to the virilization of a practically healthy newborn female child. In this case, to establish the clinical form of hermaphroditism in a child with positive X-chromatin (46,XX karyotype), it is necessary to determine the excretion of 17-ketosteroids in the urine, the level of 17-hydroxyprogesterone in the blood (100-1000 times higher than in healthy newborns) . With an increase in these indicators, congenital hyperplasia of the adrenal cortex is diagnosed. With repeated determination of the level of sodium and potassium in the blood serum, hyperkalemia and hyponatremia indicate congenital adrenal hyperplasia. Diagnostic laparoscopy and / or laparotomy at the age of 6-18 months. life with a histological examination of the gonads will help to finally establish the diagnosis in non-adrenal forms of false female hermaphroditism.

2. Male false hermaphroditism is diagnosed in newborns with negative sex chromatin. Here, differential diagnosis is complex and fundamentally important for the final choice of sex, since, despite a significant degree of feminization of the external genitalia, some patients in the pubertal period may have spontaneous puberty with satisfactory testicular function, and some not only do not have sexual development, but there is no sensitivity to exogenous hormone therapy. In newborns with negative sex chromatin, it is necessary to examine the blood for a karyotype, determine the level of testosterone and other androgenic hormones, conduct a radiological study (sdintigraphy, retrograde urethrography, pyelography), ultrasound to determine the structure of internal organs. With an increase in testosterone in the blood of newborns, it is necessary to conduct a test with testosterone - intramuscular injection of human chorionic gonadotropin at a dose of 500 IU 4 times intramuscularly for 3 days. If there is no increase in testosterone in the blood against the background of ongoing therapy, testicular feminization is diagnosed, and the newborn should be attributed to the female sex, since masculinization in these newborns will never occur even with the introduction of exogenous androgens.

3. Most children with true hermaphroditism have a 46,XX karyotype or mosaicism involving the X chromosome. They are chromatin positive. Definitive diagnosis after establishing an elevated testosterone level and a normal or slightly elevated 17-hydroxyprogesterone level. Clarification of the level of biochemical disorders is possible only in specialized centers.

There is an opinion that the establishment of the sex of the child depends primarily on the functional anatomy of the external genital organs, and not on the chromosomal iol. If the length of the penis does not exceed 2 cm, then it is in the interests of the child to classify it as a female, since there is little hope that when he gets up as an adult, the penis will be able to adequately perform its function.

B. Determination of the karyotype. To determine the chromosomal analysis, it is necessary to take a sample of peripheral blood. The choice of initial therapy is made before the results of the karyotype (this study usually takes 5-7 days) based on the results of the analysis of sex chromatin.

The differential diagnosis is carried out with false female hermaphroditism with conditions caused by the introduction of mothers of androgens or increased production of her own androgens, as well as increased production of androgens in the fetus due to congenital adrenal hyperplasia.

True hermaphroditism is rare, and testing of testosterone levels is usually not necessary until congenital adrenal hyperplasia has been ruled out.

Chromosomal abnormalities rarely lead to the problem of unclear sex. These primarily include Turner's syndrome (anomaly 45,X), Klinefelter's syndrome (47,XXY).

Treatment. The most important aspect of treatment is to maintain secrecy in the interests of parents and the child during diagnostic tests. Until the sex is established, it is necessary to avoid the use of certain words indicating the sex of the child, so as not to set the parents on one or another gender of their child, and also in the medical history of the mother and newborn not to indicate the sex of the child and not to fill out a birth certificate.

Surgical correction of the external genitalia at an early age (up to 2 years). If necessary, hormone replacement therapy is prescribed during puberty.

Removal of gonads and internal genitalia that do not correspond to the chosen sex is possible during laparotomy at the age of 6-18 months. life with non-adrenal forms of false female hermaphroditism.

If necessary, congenital hyperplasia of the adrenal cortex - replacement therapy with gluco- and mineralocorticoids (for more details, see paragraph 8.3). Surgical correction of the external genitalia is carried out with an uncomplicated form up to 2 years, with a salt-losing form - at 5-6 years.

Forecast. The outcome of treatment is determined both by the state of the child's physical health and his social adaptation in adulthood. In the vast majority of cases - infertility.