title: The challenges in diagnosis and gender assignment in disorders of sex development presenting to a pediatric surgical unit in a developing country: the role of laparoscopy and simple tests for gender identity.
abstract: OBJECTIVE
  We aimed to assess how the diagnosis and determination of gender identity of disorders of sex development (DSD) is different in a developing country from Western medicine, and whether a pediatric surgery department can determine the underlying diagnosis and use simple tools to determine the likely gender identity (GI).
  
  
  METHODS
  We reviewed the records of DSD patients admitted to the Department of Pediatric Surgery, Chittagong Medical College & Hospital (CMCH), Chittagong, Bangladesh, from January 2006 to December 2012 and performed a cross-sectional study on GI and gender-related behavior in these patients during the year 2012. DSD boys and girls answered a GI interview and had their gender role behavior assessed by observations of structural toy play and analyzed for differences in scores.
  
  
  RESULTS
  This cohort of DSD patients presented in mid-childhood (6 months-16 years, mean 6.9 years) rather than infancy, and 30% came from consanguineous unions. Congenital adrenal hyperplasia (CAH) constituted only 11 of 50 (22%) of the DSD cohort, and not all families had access to steroid hormone replacement. A simple assessment of GI and gender-related behavior allowed effective gender assignment, as there was significant difference between DSD boys and girls in GI and gender-related behavior score.
  
  
  CONCLUSIONS
  DSD management in Bangladesh provides some unique challenges because of limited resources. A national reference laboratory for biochemical and genetic testing and development of a quaternary referral center for DSD patients will be helpful. Continued use of the GI interview and gender-related behavior study will enable effective interim decisions about diagnosis and management.
authors.affiliation: Department of Pediatric Surgery, Chittagong Medical College & Hospital, Chittagong, Bangladesh.
authors.forename: Tanvir K
authors.initials: TK
authors.lastname: Chowdhury
authors.affiliation: Department of Pediatric Surgery, Chittagong Medical College & Hospital, Chittagong, Bangladesh.
authors.forename: Mahfuzul
authors.initials: M
authors.lastname: Kabir
authors.affiliation: Department of Pediatric Surgery, Chittagong Medical College & Hospital, Chittagong, Bangladesh.
authors.forename: Md Zonaid
authors.initials: MZ
authors.lastname: Chowdhury
authors.affiliation: Department of Urology, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Australia.
authors.forename: John M
authors.initials: JM
authors.lastname: Hutson
authors.affiliation: Department of Pediatric Surgery, Chittagong Medical College & Hospital, Chittagong, Bangladesh. Electronic address: proftahmina@gmail.com.
authors.forename: Tahmina
authors.initials: T
authors.lastname: Banu
mesh_terms: D000293:Adolescent; D000312:Adrenal Hyperplasia, Congenital / Q000453:epidemiology; D001459:Bangladesh; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003558:Cystoscopy; D012734:Disorders of Sex Development / Q000175:diagnosis* / Q000453:epidemiology; D005260:Female; D005783:Gender Identity; D006801:Humans; D007223:Infant; D010535:Laparoscopy; D008297:Male
keywords: Developing country; Disorders of sex development; Gender identity; Laparoscopy