title: Utilization of health care services and satisfaction with care in adults affected by disorders of sex development (DSD).
abstract: BACKGROUND
  Disorders of sex development (DSD) are a heterogeneous group of rare genetic disorders of sex determination or differentiation. Evidence-based guidelines concerning gender assignment and surgical and hormonal treatment are limited for many DSD entities, and health care is highly fragmented across various sub-specialties and settings. A lack of informed consent, secrecy about the condition, shame, and impaired sexual and psychosocial functioning may affect satisfaction with care.
  
  
  OBJECTIVE
  The main goal of this study was to describe satisfaction with care in individuals with DSD and to identify factors associated with low satisfaction with care. METHODS/MAIN MEASURES: Using both biological (chromosomes) and social categories (sex of rearing), we classified participants according to the nomenclature of the European Society for Pediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society (ESPE/LWPES) consensus statement. We used standardized measures to assess satisfaction with care (CSQ-8), health-related quality of life (SF-36), psychological symptoms (BSI), and gender identity (FGI), in addition to self-constructed questionnaires probing experiences with health care and access to self-help groups.
  
  
  METHODS
  A total of 110 adults were recruited between January 2005 and December 2007 in four study centers in Germany, Austria, and German-speaking Switzerland.
  
  
  RESULTS
  Reports of half the participants scored below the cut-off indicating low quality of care. Women with XX DSD conditions and virilization (i.e., congenital adrenal hyperplasia) reported the highest scores for satisfaction with care, and women with XY DSD conditions and complete lack of androgen effects reported the lowest scores. Satisfaction with care was positively associated with indicators of psychological well-being.
  
  
  CONCLUSIONS
  Satisfaction with care is lowest among participants with the rarest conditions, highlighting the lack of evidence-based recommendations and the lack of coordination of care. Associations of satisfaction and well-being indicate the need to ensure access to mental health services.
authors.affiliation: Hospital for Children and Adolescents, University Lübeck, Lübeck, Germany, Ute.thyen@uksh.de.
authors.forename: Ute
authors.initials: U
authors.lastname: Thyen
authors.forename: Anke
authors.initials: A
authors.lastname: Lux
authors.forename: Martina
authors.initials: M
authors.lastname: Jürgensen
authors.forename: Olaf
authors.initials: O
authors.lastname: Hiort
authors.forename: Birgit
authors.initials: B
authors.lastname: Köhler
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D012734:Disorders of Sex Development / Q000523:psychology* / Q000628:therapy*; D005060:Europe; D005260:Female; D005783:Gender Identity; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life; D012307:Risk Factors; D057830:Gender-Affirming Surgery / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D055815:Young Adult