Medicine:Partial androgen insensitivity syndrome

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Partial androgen insensitivity syndrome
Other namesPartial androgen resistance syndrome; Reifenstein syndrome
Androgen receptor 3-d model.jpg
AIS results when the function of the androgen receptor (AR) is impaired. The AR protein (pictured) mediates the effects of androgens in the human body.

Partial androgen insensitivity syndrome (PAIS) is a condition that results in the partial inability of the cell to respond to androgens.[1][2][3] It is an X linked recessive condition. The partial unresponsiveness of the cell to the presence of androgenic hormones impairs the masculinization of male genitalia in the developing fetus, as well as the development of male secondary sexual characteristics at puberty, but does not significantly impair female genital or sexual development.[3][4] As such, the insensitivity to androgens is clinically significant only when it occurs in individuals with a Y chromosome (or more specifically, an SRY gene).[1] Clinical features include ambiguous genitalia at birth and primary amenhorrhoea with clitoromegaly with inguinal masses. Müllerian structures are not present in the individual.

PAIS is one of three types of androgen insensitivity syndrome, which is divided into three categories that are differentiated by the degree of genital masculinization: complete androgen insensitivity syndrome (CAIS) is indicated when the external genitalia is that of a typical female, mild androgen insensitivity syndrome (MAIS) is indicated when the external genitalia is that of a typical male, and partial androgen insensitivity syndrome (PAIS) is indicated when the external genitalia is partially, but not fully masculinized.[1][2][5][6][7][8][9][10][11] Androgen insensitivity syndrome is the largest single entity that leads to 46,XY undermasculinization.[12] PAIS has a similar presentation and is difficult to distinguish from 5α-reductase type 2 deficiency, especially before puberty.[13][14][15]

There are differing opinions on whether treatment is necessary. Treatment may include irreversible and far reaching surgical operations such as gonadectomy, as well as hormone replacement therapy, or vaginoplasty if the patient has desire to engage in penetrative sex.

Signs and symptoms

A supplemental system of phenotypic grading that uses seven classes instead of the traditional three was proposed by pediatric endocrinologist Charmian A. Quigley et al. in 1995.[3] The first six grades of the scale, grades 1 through 6, are differentiated by the degree of genital masculinization; grade 1 is indicated when the external genitalia is fully masculinized, grade 6 is indicated when the external genitalia is fully feminized, and grades 2 through 5 quantify four degrees of increasingly feminized genitalia that lie in the interim.[3] Grade 7 is indistinguishable from grade 6 until puberty, and is thereafter differentiated by the presence of secondary terminal hair; grade 6 is indicated when secondary terminal hair is present, whereas grade 7 is indicated when it is absent.[3] The Quigley scale can be used in conjunction with the traditional three classes of AIS to provide additional information regarding the degree of genital masculinization, and is particularly useful when the diagnosis is PAIS.[2][16]

Left, 19-year-old man with grade 3 PAIS before initiation of androgen therapy. Right, Habitus after 3.5 years of androgen treatment.[17]

Partial androgen insensitivity syndrome is diagnosed when the degree of androgen insensitivity in an individual with a 46,XY karyotype is great enough to partially prevent the masculinization of the genitalia, but is not great enough to completely prevent genital masculinization.[1][2][18][19] This includes any phenotype resulting from androgen insensitivity where the genitalia is partially, but not completely masculinized. Genital ambiguities are frequently detected during clinical examination at birth, and consequently, a PAIS diagnosis can be made during infancy as part of a differential diagnostic workup.[20][21]

Pubertal undervirilization is common, including gynecomastia, decreased secondary terminal hair, and/or a high pitched voice.[22] The phallic structure ranges from a penis with varying degrees of diminished size and hypospadias to a slightly enlarged clitoris.[1][2][3] Wolffian structures (the epididymides, vasa deferentia, and seminal vesicles) are typically partially or fully developed.[2] The prostate is typically small or impalpable.[23][24] Müllerian remnants are rare, but have been reported.[25][26]

The gonads in individuals with PAIS are testes, regardless of phenotype;[2] during the embryonic stage of development, testes form in an androgen-independent process that occurs due to the influence of the SRY gene on the Y chromosome.[27][28] Cryptorchidism is common,[1][2] and carries with it a 50% risk of germ cell malignancy.[29] If the testes are located intrascrotally, there may still be significant risk of germ cell malignancy; studies have not yet been published to assess this risk.[29]

Predominantly male phenotypes vary in the degree of genital undermasculinization to include micropenis, chordee, bifid scrotum, and/or pseudovaginal perineoscrotal hypospadias.[1][18][30] Impotence may be fairly common, depending on phenotypic features; in one study of 15 males with PAIS, 80% of those interviewed indicated that they had some degree of impotence.[31] Anejaculation appears to occur somewhat independently of impotence; some men are still able to ejaculate despite impotence, and others without erectile difficulties cannot.[23][32][33][34] Predominantly female phenotypes include a variable degree of labial fusion and clitoromegaly.[3] Ambiguous phenotypic states include a phallic structure that is intermediate between a clitoris and a penis, and a single perineal orifice that connects to both the urethra and the vagina (i.e. urogenital sinus).[3] At birth, it may not be possible to immediately differentiate the external genitalia of individuals with PAIS as being either male or female,[1][35] although the majority of individuals with PAIS are raised male.[1]

Schematic representation of the Quigley scale. Grades 2 through 5 quantify four degrees of increasingly feminized genitalia that correspond to PAIS. Grades 1 and 6/7 correspond to MAIS and CAIS, respectively.[3]

Given the wide diversity of phenotypes associated with PAIS, the diagnosis is often further specified by assessing genital masculinization.[2][3] Grades 2 through 5 of the Quigley scale quantify four degrees of increasingly feminized genitalia that correspond to PAIS.[3]

Grade 2, the mildest form of PAIS, presents with a predominantly male phenotype that presents with minor signs of undermasculinized genitalia, such as isolated hypospadias,[3] which can be severe.[1] Hypospadias may manifest with a partially formed channel from the urethral opening to the glans.[3][36] Until recently, it was thought that isolated micropenis was not a manifestation of PAIS.[1] However, in 2010, two cases of PAIS manifesting with isolated micropenis were documented.[37]

Grade 4 PAIS with bifid scrotum, microphallus-like clitoris, and urethral orifice with terminal sinus urogenitalis[38]

Grade 3, the most common phenotypic form of PAIS,[1][31] features a predominantly male phenotype that is more severely undermasculinized, and typically presents with micropenis and pseudovaginal perineoscrotal hypospadias with bifid scrotum.[3]

Grade 4 presents with a gender ambiguous phenotype, including a phallic structure that is intermediate between a clitoris and a penis.[3] The urethra typically opens into a common channel with the vagina (i.e. urogenital sinus).[3]

Grade 5, the form of PAIS with the greatest degree of androgen insensitivity, presents with a mostly female phenotype, including separate urethral and vaginal orifices, but also shows signs of slight masculinization including mild clitoromegaly and/or partial labial fusion.[1][3]

Previously, it was erroneously thought that individuals with PAIS were always infertile; at least one case report has been published that describes fertile men that fit the criteria for grade 2 PAIS (micropenis, penile hypospadias, and gynecomastia).[39]

Comorbidity

Histopathology of testicular tissue showing immature germ cells and spermatogonia with decreased tubular diameter. Scattered groups of Leydig cells appearing immature.[40]

All forms of androgen insensitivity are associated with infertility, though exceptions have been reported for both the mild and partial forms.[4][5][7][39][41][42]

PAIS is associated with a 50% risk of germ cell malignancy when the testes are undescended.[29] If the testes are located intrascrotally, there may still be significant risk of germ cell malignancy; studies have not yet been published to assess this risk.[29] Some men with PAIS may experience sexual dysfunction including impotence and anejaculation.[23][31][32][33][34] A few AR mutations that cause PAIS are also associated with prostate[43][44] and breast[36][45] cancers.

Vaginal hypoplasia, a relatively frequent finding in CAIS and some forms of PAIS,[46][47] is associated with sexual difficulties including vaginal penetration difficulties and dyspareunia.[47][48]

There are indications that individuals with an intersex condition may be more prone to psychological difficulties, due at least in part to parental attitudes and behaviors,[49] and concludes that preventative long-term psychological counseling for parents as well as for affected individuals should be initiated at the time of diagnosis. More recent research based on interviews of people with intersex variations indicate a need for more family protection from intervention and more family support. [50]

Lifespan is not thought to be affected by AIS.[1]

Diagnosis

Unfortunately, the number of differentials to consider for PAIS is particularly large.[1] Prompt diagnosis is particularly urgent when a child is born with ambiguous genitalia, as some causes are associated with potentially life-threatening adrenal crises.[27] Determination of testosterone, testosterone precursors and dihydrotestosterone (DHT) at baseline and / or after human chorionic gonadotropin (hCG) stimulation can be used to exclude such defects in androgen biosynthesis.[2]

Approximately one half of all 46,XY individuals born with ambiguous genitalia will not receive a definitive diagnosis.[51] Androgen receptor (AR) gene mutations cannot be found in 27% [6][32] to 72% [52] of individuals with PAIS. As a result, genetic analysis can be used to confirm a diagnosis of PAIS, but it cannot be used to rule out PAIS.[53] Evidence of abnormal androgen binding in a genital skin fibroblast study has long been the gold standard for the diagnosis of PAIS,[3][54] even when an AR mutation is not present.[51] However, some cases of PAIS, including AR-mutant-positive cases,[33] will show normal androgen binding. A family history consistent with X-linked inheritance is more commonly found in AR-mutant-positive cases than AR-mutant-negative cases.[53]

The use of dynamic endocrine tests is particularly helpful in isolating a diagnosis of PAIS.[1][12] One such test is the human chorionic gonadotropin (hCG) stimulation test. If the gonads are testes, there will be an increase in the level of serum testosterone in response to the hCG, regardless of testicular descent.[1] The magnitude of the testosterone increase can help differentiate between androgen resistance and gonadal dysgenesis, as does evidence of a uterus on ultrasound examination.[1] Testicular function can also be assessed by measuring serum anti-Müllerian hormone levels, which in turn can further differentiate PAIS from gonadal dysgenesis and bilateral anorchia.[1]

Another useful dynamic test involves measuring the response to exogenous steroids; individuals with AIS show a decreased response in serum sex hormone binding globulin (SHBG) after a short term administration of anabolic steroids.[55][56] Two studies [55][56] indicate that measuring the response in SHBG after the administration of stanozolol could help to differentiate individuals with PAIS from those with other causes of ambiguous genitalia, although the response in individuals with predominantly male phenotypes overlaps somewhat with the response in normal males.[citation needed]

Management

Management of AIS is currently limited to symptomatic management; methods to correct a malfunctioning androgen receptor protein that result from an AR gene mutation are not currently available. Areas of management include sex assignment, genitoplasty, gonadectomy in relation to tumor risk, hormone replacement therapy, and genetic and psychological counseling. Non-consensual interventions are still often performed, although general awareness on the resulting psychological traumatization is rising.[50]

Sex assignment

The decision of whether to raise an individual with PAIS as a boy or a girl may not be obvious; grades 3 and 4 in particular present with a phenotype that may be difficult to classify as primarily male or female, and some will be incapable of virilization at puberty.[1][31][35] Parents of an affected newborn should seek immediate help at a center with an experienced multidisciplinary team, and should avoid gender assignment beforehand.[29] Older guidelines from 2006 advised against waiting for the child to decide for themselves.[29] According to them, key considerations involved in assigning gender include the appearance of the genitalia,[29] the extent to which the child can virilize at puberty,[2] surgical options and the postoperative sexual function of the genitalia,[32][46][57] genitoplasty complexity,[29] potential for fertility,[29] and the projected gender identity of the child.[58] The majority of individuals with PAIS are raised male, although a large portion are assigned female.[1] More recently, the interests of intersex people themselves are being taken into consideration by the medical community. Some parents have pushed their children with intersex variations to display gender normative roles and behaviours, or to engage in hormonal and surgical interventions to make their bodies appear more aesthetically 'normative'. Research based on interviews of people with intersex variations indicate a need for more family protection from intervention and more family support. [50] Intersex people who have been involuntarily surgically altered at birth often suffer from depression, anxiety, and gender dysphoria.[59][60][61][62] The World Health Organization (WHO) standard of care is to delay surgery until the child is old enough to participate in informed consent, performing intersex genital surgeries on newborn infants is considered a human rights violation, including by the WHO.[63][64]

Virilization capacity can be assessed by measuring the response to a trial of exogenous androgens; some studies have measured the growth of the phallus in response to exogenous testosterone[35] or dihydrotestosterone,[4] while others have measured the change in sex hormone binding globulin (SHBG) in response to the artificial androgen stanozolol to assess androgen sensitivity.[55][56] Some experts have cautioned that it remains to be proved that a good response to exogenous androgens in neonates is a good predictor of androgen response at puberty.[2] If a mutation in the AR gene is found, it is important to determine whether the mutation is inherited or de novo (i.e. a somatic mutation); a certain amount of the wild-type androgen receptor will be present in cases of somatic mutation, which can induce virilization at puberty.[35] A genital skin fibroblast study [3][54] and a human chorionic gonadotropin (hCG) stimulation test [12] may also provide information helpful in the assessment of virilization capacity.

Psychosexual development is influenced by many factors, including the timing, amount, and type of androgen exposure, receptor functionality, and environment, and is thus difficult to predict.[57][58][65][66][67][68] Gender identity begins to develop before 3 years of age,[69] although the earliest age at which it can be reliably assessed has yet to be determined.[29] Approximately 25% of individuals with PAIS are dissatisfied with their assigned gender, regardless of being raised as male or female.[24] One study reports that 46,XY individuals born with micropenis and no hypospadias are better off being raised male, despite the success of some being raised female.[70] Studies involving the more ambiguous phenotypic forms of PAIS are less decisive.[24][31] Homosexuality with respect to assigned gender [18] and atypical gender role behavior [29] are known to occur more frequently in individual with PAIS, and may occur with or without gender dysphoria; neither should be interpreted as an indication of incorrect gender assignment.[29] If an affected child does express feelings of gender dysphoria, the opportunity to explore such feelings with a psychologist experienced in treating intersex conditions should be accommodated.[29] If feelings of gender dysphoria persist, gender reassignment should be initiated, possibly with the aid of a specialist in the field.[29]

Genitoplasty

Genitoplasty, unlike gender assignment, can be irreversible,[53] and there is no guarantee that adult gender identity will develop as assigned despite surgical intervention.[57] Some aspects of genitoplasty are still being debated; a variety of different opinions have been presented by professionals, self-help groups, and patients over the last few decades.[2][71] Points of consideration include what conditions justify genitoplasty, the extent and type of genitoplasty that should be employed, when genitoplasty should be performed, and what the goals of genitoplasty should be.[24][29][57][58][72] Gender assignment itself does not predicate the need for immediate genitoplasty; in some cases, surgical intervention can be delayed to allow the affected child to reach an age and maturity sufficient to have a role in such decisions.[53] Some studies suggest that early surgeries can still produce satisfactory outcomes,[24][73] while others suggest it to be unlikely.[72] Even surgeries that are planned as one-stage procedures often require further major surgery.[72] Scarring and tissue loss that result from repeated surgical procedures are of particular concern, due to the presumed negative impact on sexual function.[24]

While it is thought that feminizing genitoplasty typically requires fewer surgeries to achieve an acceptable result and results in fewer urologic difficulties,[24] there is no evidence that feminizing surgery results in a better psychosocial outcome.[57] In one study,[24] individuals with grade 3 PAIS who were raised male rated their body image and sexual function similarly to those who were raised female, even though they were more likely to have genitalia that were abnormal in size and appearance; more than half of the male participants had a stretched penile length that was below 2.5 standard deviations of the mean, while only 6% of female participants presented with a short vagina in adulthood, and participating physicians gave a lower cosmetic rating to the surgical results of the men than the women. Both male and female participants cited the appearance of their genitalia as being the greatest contributing factor to their dissatisfaction with their body image. In two larger studies,[74][75] the common predictor of gender reassignment was stigmatization related to having an intersex condition.

The outcome of masculinizing genitoplasty is dependent on the amount of erectile tissue and the extent of hypospadias.[29] Procedures include correction of penile curvature and chordee, reconstruction of the urethra, hypospadias correction, orchidopexy, and Müllerian remnant removal to prevent infection and pseudo-incontinence.[1][76] Erectile prosthesis may be inserted in cases of successful neophalloplasty in adulthood, although it has a high morbidity.[29] Additional surgeries may be required to correct postsurgical complications such as stenosis of the anastomosis between the native urethra and the graft, urethral fistulas, and posterior displacement of the balanic meatus.[76] Successful masculinizing genitoplasty performed on individuals with grade 3 PAIS often requires multiple surgeries.[24]

A 15-year-old female with a history of CAH who underwent a single-stage feminizing genitoplasty-reduction clitoroplasty and a pull-through vaginoplasty at 2 years of age. She presented with pain and enlargement of the clitoral region.[77]

If feminizing genitoplasty is performed in infancy, the result will need to be refined at puberty through additional surgery.[78] Procedures include clitoral reduction / recession, labiaplasty, repair of the common urogenital sinus, vaginoplasty, and vaginal dilation through non-surgical pressure methods.[29][47][57][78] Clitoral reduction / recession surgery carries with it the risk of necrosis[78] as well as the risk of impairing the sexual function of the genitalia,[57] and thus should not be performed for less severe clitoromegaly.[29] Clitoral surgery should be focused on function rather than appearance, with care being taken to spare the erectile function and innervation of the clitoris.[29] If PAIS presents with a common urogenital sinus, the American Academy of Pediatrics currently recommends that surgery to separate the urethra from the vagina be performed at an early age.[79] As is the case for CAIS, vaginal dilation using pressure dilation methods should be attempted before the surgical creation of a neovagina is considered, and neither should be performed before puberty.[29][47] Complications of feminizing genitoplasty can include vaginal stenosis, meatal stenosis, vaginourethral fistula, female hypospadias, urinary tract injuries, and recurrent clitoromegaly.[47][77] Successful feminizing genitoplasty performed on individuals with grade 3 PAIS often requires multiple surgeries, although more surgeries are typically required for successful masculinizing genitoplasty in this population.[24]

Many surgical procedures have been developed to create a neovagina, as none of them is ideal.[47] Surgical intervention should be considered only after non-surgical pressure dilation methods have failed to produce a satisfactory result.[47] Neovaginoplasty can be performed using skin grafts, a segment of bowel, ileum, peritoneum, Interceed,[80][81] buccal mucosa, amnion, or dura mater.[47][77][82] Success of such methods should be determined by sexual function, and not by vaginal length alone, as has been done in the past.[77] Ileal or cecal segments may be problematic because of a shorter mesentery, which may produce tension on the neovagina, leading to stenosis.[77] The sigmoid neovagina is thought to be self-lubricating, without the excess mucus production associated with segments of small bowel.[77] Vaginoplasty may create scarring at the introitus (the vaginal opening), requiring additional surgery to correct. Vaginal dilators are required postoperatively to prevent vaginal stenosis from scarring.[46][47] Other complications include bladder and bowel injuries.[47] Yearly exams are required, as neovaginoplasty carries a risk of carcinoma,[47] although carcinoma of the neovagina is uncommon.[77][82] Neither neovaginoplasty nor vaginal dilation should be performed before puberty.[29][47]

Gonadectomy

Gonadectomy at time of diagnosis is the current recommendation for PAIS if presenting with cryptorchidism. The risk of malignancy when testes are located intrascrotally is unknown; the current recommendation is to biopsy the testes at puberty, allowing investigation of at least 30 seminiferous tubules, with diagnosis preferably based on OCT3/4 immunohistochemistry, followed by regular examinations.[29] Hormone replacement therapy is required after gonadectomy, and should be modulated over time to replicate the hormone levels naturally present in the body during the various stages of puberty.[29] Artificially induced puberty results in the same, normal development of secondary sexual characteristics, growth spurt, and bone mineral accumulation.[29] Women with PAIS may have a tendency towards bone mineralization deficiency, although this increase is thought to be less than is typically seen in CAIS, and is similarly managed.[83]

Hormonal replacement therapy

Testosterone has been used to successfully treat undervirilization in some [17] but not all [84] men with PAIS, despite having supraphysiological levels of testosterone to start with.[17][85] Treatment options include transdermal gels or patches, oral or injectable testosterone undecanoate, other injectable testosterone esters, testosterone pellets, or buccal testosterone systems.[86] Supraphysiological doses may be required to achieve the desired physiological effect,[17][29][87] which may be difficult to achieve using non-injectable testosterone preparations. Exogenous testosterone supplementation in unaffected men can produce various unwanted side effects, including prostatic hypertrophy, polycythemia, gynecomastia, hair loss, acne, and the suppression of the hypothalamic-pituitary-gonadal axis, resulting in the reduction of gonadotropins (i.e., luteinizing hormone and follicle-stimulating hormone) and spermatogenic defect.[88][89] These effects may not manifest at all in men with AIS, or might only manifest at a much higher concentration of testosterone, depending on the degree of androgen insensitivity.[17][84][85] Those undergoing high dose androgen therapy should be monitored for safety and efficacy of treatment, possibly including regular breast[17] and prostate[88] examinations. Some individuals with PAIS have a sufficiently high sperm count to father children; at least one case report has been published that describes fertile men who fit the criteria for grade 2 PAIS (micropenis, penile hypospadias, and gynecomastia).[39] Several publications have indicated that testosterone treatment can correct low sperm counts in men with MAIS.[1][87] At least one case report has been published that documents the efficacy of treating a low sperm-count with tamoxifen in an individual with PAIS.[90]

Counseling

Depending on phenotypic features, impotence and other sexual problems such as anejaculation or sexual aversion may be fairly common among individuals with PAIS,[23][31][32][33][34] but do not necessarily indicate low libido.[29][31] Support groups for individuals with PAIS may help affected individuals discuss their concerns more comfortably.[29] Some individuals with PAIS may try to avoid intimate relationships out of fear of rejection; individual therapy may help some to overcome social anxiety, and restore focus to interpersonal relationships instead of solely on sexual function and activity.[29]

Society and culture

Adults with partial androgen insensitivity syndrome include Australian-Maltese advocate Tony Briffa, considered to be the world's first openly intersex mayor and public office-bearer.[91] Briffa served as Deputy Mayor of the City of Hobsons Bay, Victoria, between 2009 and 2011, and Mayor between 2011 and 2012.[92][91][93][94][95][96][excessive citations]

In history, the Roman sophist and philosopher Favorinus of Arelate has been described as having partial androgen insensitivity syndrome.[97][98]

Notable people with PAIS

Sentencia SU 337/99, Colombia

In Sentencia SU-337/99, of May 12, 1999, the Constitutional Court of Colombia determined that "qualified and persistent" informed consent is required for genital surgeries in children. The Court ruled in the case of XX, an 8-year old with ambiguous genitalia, androgen insensitivity and XY chromosomes, raised as a girl. Doctors recommended feminizing surgeries, including a gonadectomy, vaginoplasty and clitoroplasty before puberty, but the hospital would not proceed without the consent of the Colombian Institute of Family Welfare and the Office of the Public Advocate. The mother brought a case against Institute and Office of the Public Advocate, seeking to provide substitute consent. The mother argued that “the capacity to decide, it would be too late and would prevent normal psychological, physical, and social development”.[107]

The Court refused the mother's claim. It questioned the urgency of the case, argued by medical teams. Civil rights advocates and a minority of doctors favored deferring treatment due to lack of evidence and the irreversible nature of the proposed interventions. The Court observed that advocates of surgery were more numerous than opponents, alternatives to surgery were not entirely feasible, and surgeries had improved, “making it less likely that sexual sensitivity would be destroyed; and the medical community was improving communication with parents”.[107]

The Court determined that a constitutional protection of a right to free development of personality meant that a child's autonomy increases with age, including the development of a gender identity and bodily awareness.[108] It determined that the best interests of the child were protected by allowing the child to determine their own gender identity.[109] The Court determined that genital surgeries should not be conducted on children over the age of five, and that multidisciplinary teams should assess children's needs on a case-by-case basis.[110][107][111]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 "Androgen resistance". Best Pract. Res. Clin. Endocrinol. Metab. 20 (4): 577–98. December 2006. doi:10.1016/j.beem.2006.11.003. PMID 17161333. 
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 "Androgen insensitivity syndrome: clinical features and molecular defects". Hormones (Athens) 7 (3): 217–29. 2008. doi:10.14310/horm.2002.1201. PMID 18694860. 
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 "Androgen receptor defects: historical, clinical, and molecular perspectives". Endocr. Rev. 16 (3): 271–321. June 1995. doi:10.1210/edrv-16-3-271. PMID 7671849. 
  4. ↑ 4.0 4.1 4.2 "An androgen receptor gene mutation (E653K) in a family with congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency as well as in partial androgen insensitivity". J. Clin. Endocrinol. Metab. 87 (6): 2623–8. June 2002. doi:10.1210/jc.87.6.2623. PMID 12050225. 
  5. ↑ 5.0 5.1 "Detailed functional studies on androgen receptor mild mutations demonstrate their association with male infertility". Clin. Endocrinol. 68 (4): 580–8. April 2008. doi:10.1111/j.1365-2265.2007.03069.x. PMID 17970778. 
  6. ↑ 6.0 6.1 "Male infertility and androgen receptor gene mutations: clinical features and identification of seven novel mutations". Clin. Endocrinol. 65 (5): 606–10. November 2006. doi:10.1111/j.1365-2265.2006.02635.x. PMID 17054461. 
  7. ↑ 7.0 7.1 "Male infertility and the involvement of the X chromosome". Hum. Reprod. Update 15 (6): 623–37. 2009. doi:10.1093/humupd/dmp023. PMID 19515807. 
  8. ↑ "Incidental detection of Sertoli-Leydig cell tumor by FDG PET/CT imaging in a patient with androgen insensitivity syndrome". Ann Nucl Med 24 (1): 35–9. January 2010. doi:10.1007/s12149-009-0321-x. PMID 19957213. 
  9. ↑ "Male infertility and variation in CAG repeat length in the androgen receptor gene: a meta-analysis". J. Clin. Endocrinol. Metab. 92 (11): 4319–26. November 2007. doi:10.1210/jc.2007-1110. PMID 17684052. 
  10. ↑ "Impaired nuclear translocation, nuclear matrix targeting, and intranuclear mobility of mutant androgen receptors carrying amino acid substitutions in the deoxyribonucleic acid-binding domain derived from androgen insensitivity syndrome patients". J. Clin. Endocrinol. Metab. 90 (11): 6162–9. November 2005. doi:10.1210/jc.2005-0179. PMID 16118342. 
  11. ↑ "Molecular pathology of the androgen receptor in male (in)fertility". Reprod. Biomed. Online 10 (1): 42–8. January 2005. doi:10.1016/S1472-6483(10)60802-4. PMID 15705293. 
  12. ↑ 12.0 12.1 12.2 "Assessment of the gonadotrophin-gonadal axis in androgen insensitivity syndrome". Arch. Dis. Child. 80 (4): 324–9. April 1999. doi:10.1136/adc.80.4.324. PMID 10086936. 
  13. ↑ "Undervirilization in XY newborns may hide a 5α-reductase deficiency: report of three new SRD5A2 gene mutations". International Journal of Andrology 33 (6): 841–847. December 2010. doi:10.1111/j.1365-2605.2009.01036.x. PMID 20132346. 
  14. ↑ "Clinical and Laboratorial Features That May Differentiate 46,XY DSD due to Partial Androgen Insensitivity and 5α-Reductase Type 2 Deficiency". International Journal of Endocrinology 2012: 964876. 12 December 2011. doi:10.1155/2012/964876. PMID 22194745. 
  15. ↑ "Differences of adrenal-derived androgens in 5α-reductase deficiency versus androgen insensitivity syndrome". Clinical and Translational Science 15 (3): 658–666. March 2022. doi:10.1111/cts.13184. PMID 34755921. 
  16. ↑ "Disorders linked to insufficient androgen action in male children". Hum. Reprod. Update 7 (3): 314–22. 2001. doi:10.1093/humupd/7.3.314. PMID 11392378. 
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 "Response to androgen treatment in a patient with partial androgen insensitivity and a mutation in the deoxyribonucleic acid-binding domain of the androgen receptor". J. Clin. Endocrinol. Metab. 83 (4): 1173–6. April 1998. doi:10.1210/jcem.83.4.4704. PMID 9543136. 
  18. ↑ 18.0 18.1 18.2 "Complete androgen insensitivity syndrome--a review". J Pediatr Adolesc Gynecol 21 (6): 305–10. December 2008. doi:10.1016/j.jpag.2007.09.006. PMID 19064222. 
  19. ↑ "A novel mutation c.118delA in exon 1 of the androgen receptor gene resulting in complete androgen insensitivity syndrome within a large family". Fertil. Steril. 89 (5): 1260.e3–7. May 2008. doi:10.1016/j.fertnstert.2007.04.057. PMID 17714709. 
  20. ↑ "Diagnosis of the partial androgen insensitivity syndrome during infancy". JAMA 255 (16): 2207–9. April 1986. doi:10.1001/jama.255.16.2207. PMID 3959303. 
  21. ↑ "Non-surgical management of Müllerian anomalies". Non-Invasive Management of Gynecologic Disorders. Informa Healthcare. 2008. pp. 193–202. ISBN 978-0-415-41742-6. 
  22. ↑ "Discordant measures of androgen-binding kinetics in two mutant androgen receptors causing mild or partial androgen insensitivity, respectively". J. Clin. Endocrinol. Metab. 84 (2): 805–10. February 1999. doi:10.1210/jcem.84.2.5453. PMID 10022458. 
  23. ↑ 23.0 23.1 23.2 23.3 "Genotype versus phenotype in families with androgen insensitivity syndrome". J. Clin. Endocrinol. Metab. 86 (9): 4151–60. September 2001. doi:10.1210/jcem.86.9.7825. PMID 11549642. 
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 24.6 24.7 24.8 24.9 "Ambiguous genitalia with perineoscrotal hypospadias in 46,XY individuals: long-term medical, surgical, and psychosexual outcome". Pediatrics 110 (3): e31. September 2002. doi:10.1542/peds.110.3.e31. PMID 12205281. 
  25. ↑ "Persistent Müllerian duct remnants in three siblings with partial androgen insensitivity". Horumon to Rinsho 43: 3–8. 1995. 
  26. ↑ Mazur T (August 2005). "Gender dysphoria and gender change in androgen insensitivity or micropenis". Arch Sex Behav 34 (4): 411–21. doi:10.1007/s10508-005-4341-x. PMID 16010464. 
  27. ↑ 27.0 27.1 "Disorders of sexual differentiation". Harrison's endocrinology. New York: McGraw-Hill Medical Pub. Division. 2006. pp. 161–172. ISBN 978-0-07-145744-6. 
  28. ↑ Principles and Practice of Endocrinology and Metabolism. Hagerstwon, MD: Lippincott Williams & Wilkins. 2002. pp. 852–885. ISBN 978-0-7817-4245-0. 
  29. ↑ 29.00 29.01 29.02 29.03 29.04 29.05 29.06 29.07 29.08 29.09 29.10 29.11 29.12 29.13 29.14 29.15 29.16 29.17 29.18 29.19 29.20 29.21 29.22 29.23 29.24 29.25 29.26 29.27 29.28 "Consensus statement on management of intersex disorders". Arch. Dis. Child. 91 (7): 554–63. July 2006. doi:10.1136/adc.2006.098319. PMID 16624884. 
  30. ↑ "Phenotypic diversity in siblings with partial androgen insensitivity syndrome". Arch. Dis. Child. 76 (6): 529–31. June 1997. doi:10.1136/adc.76.6.529. PMID 9245853. 
  31. ↑ 31.0 31.1 31.2 31.3 31.4 31.5 31.6 "Impaired sexual activity in male adults with partial androgen insensitivity". J. Clin. Endocrinol. Metab. 91 (9): 3310–5. September 2006. doi:10.1210/jc.2006-0218. PMID 16757528. 
  32. ↑ 32.0 32.1 32.2 32.3 32.4 "Clinical, hormonal, behavioral, and genetic characteristics of androgen insensitivity syndrome in a Brazilian cohort: five novel mutations in the androgen receptor gene". J. Clin. Endocrinol. Metab. 88 (7): 3241–50. July 2003. doi:10.1210/jc.2002-021658. PMID 12843171. 
  33. ↑ 33.0 33.1 33.2 33.3 "A novel mutation in the human androgen receptor suggests a regulatory role for the hinge region in amino-terminal and carboxy-terminal interactions". J. Clin. Endocrinol. Metab. 93 (10): 3691–6. October 2008. doi:10.1210/jc.2008-0737. PMID 18697867. 
  34. ↑ 34.0 34.1 34.2 "Severe hypospadias with genital ambiguity: adult outcome after staged hypospadias repair". Br J Urol 80 (3): 485–8. September 1997. doi:10.1046/j.1464-410x.1997.00348.x. PMID 9313674. 
  35. ↑ 35.0 35.1 35.2 35.3 "Androgen insensitivity syndrome: somatic mosaicism of the androgen receptor in seven families and consequences for sex assignment and genetic counseling". J. Clin. Endocrinol. Metab. 90 (1): 106–11. January 2005. doi:10.1210/jc.2004-0462. PMID 15522944. 
  36. ↑ 36.0 36.1 "A germline mutation in the androgen receptor gene in two brothers with breast cancer and Reifenstein syndrome". Nat. Genet. 2 (2): 132–4. October 1992. doi:10.1038/ng1092-132. PMID 1303262. 
  37. ↑ "Isolated micropenis reveals partial androgen insensitivity syndrome confirmed by molecular analysis". Asian J. Androl. 12 (4): 561–6. July 2010. doi:10.1038/aja.2010.6. PMID 20305676. 
  38. ↑ "Testicular cancer in androgen insensitivity syndrome in a Mexican population". Clin Transl Oncol 10 (12): 840–3. December 2008. doi:10.1007/s12094-008-0298-2. PMID 19068456. 
  39. ↑ 39.0 39.1 39.2 "Male fertility is compatible with an Arg(840)Cys substitution in the AR in a large Chinese family affected with divergent phenotypes of AR insensitivity syndrome". J. Clin. Endocrinol. Metab. 87 (1): 347–51. January 2002. doi:10.1210/jcem.87.1.8167. PMID 11788673. 
  40. ↑ Nichols JL, Bieber EJ, Gell JS. Case of sisters with complete androgen insensitivity syndrome and discordant Müllerian remnants. Fertil Steril. 2009;91:932e15-e18.
  41. ↑ "Complete androgen insensitivity syndrome with persistent Mullerian derivatives: a case report". J Obstet Gynaecol 25 (4): 403–5. May 2005. doi:10.1080/01443610500143226. PMID 16091340. 
  42. ↑ "Preserved male fertility despite decreased androgen sensitivity caused by a mutation in the ligand-binding domain of the androgen receptor gene". J. Clin. Endocrinol. Metab. 85 (6): 2253–9. June 2000. doi:10.1210/jcem.85.6.6626. PMID 10852459. 
  43. ↑ "A novel sequence variation in the transactivation regulating domain of the androgen receptor in two infertile Finnish men". Fertil. Steril. 79 (Suppl 3): 1647–8. June 2003. doi:10.1016/s0015-0282(03)00256-5. PMID 12801573. 
  44. ↑ "Low incidence of androgen receptor gene mutations in human prostatic tumors using single strand conformation polymorphism analysis". Prostate 28 (3): 162–71. March 1996. doi:10.1002/(SICI)1097-0045(199603)28:3<162::AID-PROS3>3.0.CO;2-H. PMID 8628719. 
  45. ↑ "Androgen receptor gene mutation in male breast cancer". Hum. Mol. Genet. 2 (11): 1799–802. November 1993. doi:10.1093/hmg/2.11.1799. PMID 8281139. 
  46. ↑ 46.0 46.1 46.2 "Normalization of the vagina by dilator treatment alone in Complete Androgen Insensitivity Syndrome and Mayer-Rokitansky-Kuster-Hauser Syndrome". Hum. Reprod. 22 (7): 2020–4. July 2007. doi:10.1093/humrep/dem074. PMID 17449508. 
  47. ↑ 47.00 47.01 47.02 47.03 47.04 47.05 47.06 47.07 47.08 47.09 47.10 47.11 "Vaginal surgery for congenital anomalies". Clin Obstet Gynecol 53 (1): 115–24. March 2010. doi:10.1097/GRF.0b013e3181cd4128. PMID 20142648. 
  48. ↑ "Sexual function in women with complete androgen insensitivity syndrome". Fertil. Steril. 80 (1): 157–64. July 2003. doi:10.1016/S0015-0282(03)00501-6. PMID 12849818. 
  49. ↑ "Long-term psychological evaluation of intersex children". Arch Sex Behav 27 (2): 125–44. April 1998. doi:10.1023/A:1018670129611. PMID 9562897. 
  50. ↑ 50.0 50.1 50.2 "Intersex and Families: Supporting Family Members With Intersex Variations". Journal of Family Strengths 17 (2). 2017. doi:10.58464/2168-670X.1345. http://digitalcommons.library.tmc.edu/jfs/vol17/iss2/8. 
  51. ↑ 51.0 51.1 "Aetiological diagnosis of male sex ambiguity: a collaborative study". Eur. J. Pediatr. 161 (1): 49–59. January 2002. doi:10.1007/s00431-001-0854-z. PMID 11808880. 
  52. ↑ "Phenotypic features, androgen receptor binding, and mutational analysis in 278 clinical cases reported as androgen insensitivity syndrome". J. Clin. Endocrinol. Metab. 85 (2): 658–65. February 2000. doi:10.1210/jcem.85.2.6337. PMID 10690872. 
  53. ↑ 53.0 53.1 53.2 53.3 Hughes IA (February 2008). "Disorders of sex development: a new definition and classification". Best Pract. Res. Clin. Endocrinol. Metab. 22 (1): 119–34. doi:10.1016/j.beem.2007.11.001. PMID 18279784. 
  54. ↑ 54.0 54.1 "Clinical and biochemical investigations and molecular analysis of subjects with mutations in the androgen receptor gene". Clin. Endocrinol. 45 (6): 733–9. December 1996. doi:10.1046/j.1365-2265.1996.8600869.x. PMID 9039340. 
  55. ↑ 55.0 55.1 55.2 "Functional assessment and clinical classification of androgen sensitivity in patients with mutations of the androgen receptor gene. German Collaborative Intersex Study Group". Eur. J. Pediatr. 156 (1): 7–14. January 1997. doi:10.1007/s004310050542. PMID 9007482. 
  56. ↑ 56.0 56.1 56.2 "Sex hormone-binding globulin response to the anabolic steroid stanozolol: evidence for its suitability as a biological androgen sensitivity test". J. Clin. Endocrinol. Metab. 68 (6): 1195–200. June 1989. doi:10.1210/jcem-68-6-1195. PMID 2723028. 
  57. ↑ 57.0 57.1 57.2 57.3 57.4 57.5 57.6 "The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study". Lancet 361 (9365): 1252–7. April 2003. doi:10.1016/S0140-6736(03)12980-7. PMID 12699952. 
  58. ↑ 58.0 58.1 58.2 Meyer-Bahlburg HF (October 1999). "Gender assignment and reassignment in 46,XY pseudohermaphroditism and related conditions". J. Clin. Endocrinol. Metab. 84 (10): 3455–8. doi:10.1210/jcem.84.10.6099. PMID 10522979. 
  59. ↑ "Invisibility and Trauma in the Intersex Community". Violence Against LGBTQ+ Persons: Research, Practice, and Advocacy. Springer International Publishing. August 11, 2021. pp. 185–194. doi:10.1007/978-3-030-52612-2_14. ISBN 978-3-030-52611-5. 
  60. ↑ "Intersex lived experience: trauma and posttraumatic growth in narratives". Psychology & Sexuality 13 (4): 912–930. October 2, 2022. doi:10.1080/19419899.2021.1938189. 
  61. ↑ "Ageing in obscurity: a critical literature review regarding older intersex people". Sexual and Reproductive Health Matters 30 (1): 2136027. December 2022. doi:10.1080/26410397.2022.2136027. PMID 36369786. 
  62. ↑ "Hermaphrodites with Attitude: Mapping the Emergence of Intersex Political Activism". The Transgender Studies Reader Remix. Routledge. August 11, 2022. doi:10.4324/9781003206255-60. ISBN 9781003206255. https://www.taylorfrancis.com/chapters/edit/10.4324/9781003206255-60/hermaphrodites-attitude-cheryl-chase. 
  63. ↑ "Intersex Variations, Human Rights, and the International Classification of Diseases". Health and Human Rights 20 (2): 205–214. December 2018. PMID 30568414. 
  64. ↑ "Legal, ethical, and human rights considerations for physicians treating children with atypical or ambiguous genitalia". Seminars in Perinatology 41 (4): 252–255. June 2017. doi:10.1053/j.semperi.2017.03.012. PMID 28478089. 
  65. ↑ "Behavioral masculinization is independent of genital masculinization in prenatally androgenized female rhesus macaques". Horm Behav 22 (4): 552–71. December 1988. doi:10.1016/0018-506X(88)90058-X. PMID 3235069. 
  66. ↑ Wallen K (April 2005). "Hormonal influences on sexually differentiated behavior in nonhuman primates". Front Neuroendocrinol 26 (1): 7–26. doi:10.1016/j.yfrne.2005.02.001. PMID 15862182. 
  67. ↑ Moore CL (1992). "The role of maternal stimulation in the development of sexual behavior and its neural basis". Annals of the New York Academy of Sciences 662 (1): 160–77. doi:10.1111/j.1749-6632.1992.tb22859.x. PMID 1456637. Bibcode: 1992NYASA.662..160M. 
  68. ↑ Wallen K (December 1996). "Nature needs nurture: the interaction of hormonal and social influences on the development of behavioral sex differences in rhesus monkeys". Horm Behav 30 (4): 364–78. doi:10.1006/hbeh.1996.0042. PMID 9047263. 
  69. ↑ "Cognitive theories of early gender development". Psychol Bull 128 (6): 903–33. November 2002. doi:10.1037/0033-2909.128.6.903. PMID 12405137. 
  70. ↑ "Congenital micropenis: long-term medical, surgical and psychosexual follow-up of individuals raised male or female". Horm. Res. 56 (1–2): 3–11. 2001. doi:10.1159/000048083. PMID 11815721. 
  71. ↑ Zucker KJ (February 2002). "Intersexuality and gender identity differentiation". J Pediatr Adolesc Gynecol 15 (1): 3–13. doi:10.1016/S1083-3188(01)00133-4. PMID 11888804. 
  72. ↑ 72.0 72.1 72.2 "Objective cosmetic and anatomical outcomes at adolescence of feminising surgery for ambiguous genitalia done in childhood". Lancet 358 (9276): 124–5. July 2001. doi:10.1016/S0140-6736(01)05343-0. PMID 11463417. 
  73. ↑ "A long-term outcome study of intersex conditions". J. Pediatr. Endocrinol. Metab. 18 (6): 555–67. June 2005. doi:10.1515/jpem.2005.18.6.555. PMID 16042323. 
  74. ↑ "Gender identity and gender transposition: longitudinal outcome study of 32 male hermaphrodites assigned as girls". J Sex Marital Ther 12 (3): 165–81. 1986. doi:10.1080/00926238608415404. PMID 3761370. 
  75. ↑ "Gender identity and gender transposition: longitudinal outcome study of 24 male hermaphrodites assigned as boys". J Sex Marital Ther 13 (2): 75–92. 1987. doi:10.1080/00926238708403881. PMID 3612827. 
  76. ↑ 76.0 76.1 "Long-term surgical results and patient satisfaction with male pseudohermaphroditism or true hermaphroditism: a cohort of 63 patients". J. Urol. 175 (5): 1878–84. May 2006. doi:10.1016/S0022-5347(05)00934-1. PMID 16600787. 
  77. ↑ 77.0 77.1 77.2 77.3 77.4 77.5 77.6 Breech LL (2008). "Complications of vaginoplasty and clitoroplasty". Reoperative pediatric surgery. Totowa, N.J: Humana. pp. 499–514. ISBN 978-1-58829-761-7. 
  78. ↑ 78.0 78.1 78.2 "Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty?". J. Urol. 161 (5): 1588–91. May 1999. doi:10.1016/S0022-5347(05)68986-0. PMID 10210421. 
  79. ↑ American Academy of Pediatrics (April 1996). "Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia.". Pediatrics 97 (4): 590–4. doi:10.1542/peds.97.4.590. PMID 8632952. 
  80. ↑ "Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in vaginal agenesis". Am. J. Obstet. Gynecol. 188 (5): 1260–4. May 2003. doi:10.1067/mob.2003.317. PMID 12748495. 
  81. ↑ "Use of Interceed Absorbable Adhesion Barrier for vaginoplasty". Obstet Gynecol 84 (6): 1048–50. December 1994. PMID 7970464. 
  82. ↑ 82.0 82.1 "Carcinoma of the neovagina: case report and review of the literature". Gynecol. Oncol. 84 (1): 171–5. January 2002. doi:10.1006/gyno.2001.6417. PMID 11748997. 
  83. ↑ "Height and bone mineral density in androgen insensitivity syndrome with mutations in the androgen receptor gene". Osteoporos Int 18 (3): 369–74. March 2007. doi:10.1007/s00198-006-0243-6. PMID 17077943. 
  84. ↑ 84.0 84.1 "Correlation of clinical, endocrine and molecular abnormalities with in vivo responses to high-dose testosterone in patients with partial androgen insensitivity syndrome". Clin. Endocrinol. 46 (4): 497–506. April 1997. doi:10.1046/j.1365-2265.1997.1140927.x. PMID 9196614. 
  85. ↑ 85.0 85.1 "Impaired spermatogenesis is not an obligate expression of receptor-defective androgen resistance". Am. J. Med. Genet. 32 (1): 100–4. January 1989. doi:10.1002/ajmg.1320320121. PMID 2705470. 
  86. ↑ "Testosterone hormone replacement therapy: state-of-the-art and emerging technologies". Pharm. Res. 23 (6): 1117–32. June 2006. doi:10.1007/s11095-006-0072-5. PMID 16755346. http://doc.rero.ch/record/312405/files/11095_2006_Article_10072.pdf. 
  87. ↑ 87.0 87.1 "Pregnancy after hormonal correction of severe spermatogenic defect due to mutation in androgen receptor gene". Lancet 344 (8925): 826–7. September 1994. doi:10.1016/S0140-6736(94)92385-X. PMID 7993455. 
  88. ↑ 88.0 88.1 Nieschlag E (September 2006). "Testosterone treatment comes of age: new options for hypogonadal men". Clin. Endocrinol. 65 (3): 275–81. doi:10.1111/j.1365-2265.2006.02618.x. PMID 16918944. 
  89. ↑ "Suppression of human spermatogenesis by testosterone implants". J. Clin. Endocrinol. Metab. 75 (5): 1326–32. November 1992. doi:10.1210/jcem.75.5.1430094. PMID 1430094. 
  90. ↑ Gooren L (June 1989). "Improvement of spermatogenesis after treatment with the antiestrogen tamoxifen in a man with the incomplete androgen insensitivity syndrome". J. Clin. Endocrinol. Metab. 68 (6): 1207–10. doi:10.1210/jcem-68-6-1207. PMID 2566621. 
  91. ↑ 91.0 91.1 "Briffa to march in mayoral robes". Star Observer. 8 December 2011. http://www.starobserver.com.au/news/briffa-to-march-in-mayoral-robes/67497. 
  92. ↑ "Intersex Mayor Elected in Australia". Advocate.com. 9 December 2011. http://www.advocate.com/news/daily-news/2011/12/09/intersex-mayor-elected-australia. 
  93. ↑ "Tony Briffa Of Australia's City Of Hobsons Bay Becomes World's First Intersex Mayor". The Huffington Post. 10 December 2011. http://www.huffingtonpost.com/2011/12/10/tony-briffa-intersex-mayor_n_1140840.html. 
  94. ↑ "World's first intersex mayor, Cr Tony Briffa does not want to be called he or she". Herald Sun. 15 April 2013. http://www.heraldsun.com.au/news/worlds-first-intersex-mayor-cr-tony-briffa-does-not-want-to-be-called-he-or-she/story-e6frf7jo-1226621092313. 
  95. ↑ "Melbourne elects Australia's first intersex Mayor". SameSame.com.au. 9 December 2011. http://www.samesame.com.au/news/7737/Melbourne-elects-Australias-first-intersex-Mayor.htm. 
  96. ↑ "Australia elects world's first intersex mayor". The Raw Story. 10 December 2011. http://www.rawstory.com/rs/2011/12/10/australia-elects-worlds-first-intersex-mayor/. 
  97. ↑ "Congenital eunuchism and Favorinus". South African Medical Journal = Suid-Afrikaanse Tydskrif vir Geneeskunde 93 (1): 73–76. January 2003. PMID 12564336. http://www.samj.org.za/index.php/samj/article/viewFile/2019/1278. 
  98. ↑ "Favorinus' disorder: Reifenstein's syndrome in Antiquity?". Janus; Revue Internationale de l'Histoire des Sciences, de la Medecine, de la Pharmacie, et de la Technique 66 (1–3): 1–13. 1978. PMID 11610651. 
  99. ↑ "About Tony". Briffa.org. 2012. http://briffa.org/about. 
  100. ↑ Senate of Australia; Community Affairs References Committee (28 March 2013), Involuntary or coerced sterilisation of people with disabilities in Australia: Thursday 28 March 2013, Canberra, http://www.aph.gov.au/hansard 
  101. ↑ "We talk to intersex individual Dr Small Luk about her gender struggles". Time Out Hong Kong. http://www.timeout.com.hk/gay-lesbian/features/72091/interview-we-talk-to-intersex-individual-dr-small-luk-about-her-gender-struggles.html. 
  102. ↑ "專訪：前跨性別難民Eliana（國際特赦組織香港分會人權雜誌春季號）Interview: Former Transgender Refugee Eliana (Amnesty International Hong Kong) Human Rights Magazine Spring Issue". 28 April 2016. http://www.inmediahk.net/node/eliana. 
  103. ↑ "Gender refugee hopes for NZ citizenship". 3 Degrees - TV3 New Zealand. 26 July 2015. http://www.3news.co.nz/tvshows/3d/gender-refugee-hopes-for-nz-citizenship-2015072616. 
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  105. ↑ "Love, complexity and inter-sectionality". Intersex Day. November 8, 2016. http://intersexday.org/en/love-complexity-intersectionality/. 
  106. ↑ один, Номер. "Бурятский лучник полжизни провел в чужом теле" (in ru). https://gazeta-n1.ru/news/society/111724/. 
  107. ↑ 107.0 107.1 107.2 International Commission of Jurists. "Sentencia SU 337/99, Constitutional Court of Colombia (12 May 1999)". https://www.icj.org/sogicasebook/sentencia-su-33799-constitutional-court-of-colombia-12-may-1999/. 
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  109. ↑ "Preferred Private Parts: Importing Intersex Autonomy for M.C. v. Aaronson". Fordham International Law Journal 37: 777. 2013. http://ir.lawnet.fordham.edu/ilj/vol37/iss3/2. 
  110. ↑ International Commission of Jurists. "Chapter six: Intersex". http://www.icj.org/sogi-casebook-introduction/chapter-six-intersex/. 
  111. ↑ International Commission of Jurists. "Sentencia SU-337/99" (in es). https://www.icj.org/wp-content/uploads/1999/05/Sentencia-SU-337-99-Constitutional-Court-of-Colombia-Spanish.pdf. 

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