From Big Medical Encyclopedia

HERMAPHRODITISM (hermaphroditismus; synonym: bisexuality, intersexuality, bisexualism) — existence at the same individual of signs of both floors.

In grech, mythologies of the son Hermes and Aphrodite the beautiful young man Germafrodit were fallen in love by the nymph of a source Salmakida; gods listened to its passionate entreaties about eternal connection with it, their bodies merged together, having formed a bisexual being.

The components defining a sex are: a set of gonosomes, generative elements of gonads, contents in an organism of sex hormones, secondary sexual characteristics, internal and external genitals, a psycho-sexual orientation (see. Floor ). In a broad sense, if any of components of a gender of the subject does not correspond to the rest, it can be carried to group of hermaphrodites. In practice hermaphrodites call subjects with a bisexual structure of external genitals; all other forms of pathology of sexual development combine in the concept «interseks», or «intersexuality» (see. Interseks ).

— the inborn pathology which in most cases is genetically caused. At quantitative or high-quality disturbances in a set of chromosomes also formation of gonads is broken: they are not formed in general (an agenesia of gonads) or support germinative structures of both floors (true, gonadal, G.), being defective anatomically, morphologically and functionally.

It is known that paramezonefralny channels are predecessors women's, mezonefralny — men's internal generative organs. The atrophy of paramezonefralny channels occurs under the influence of normal embryonal testicles; at their absence or insolvency (dysgenesis) irrespective of existence of an ovary paramezonefralny channels form in a uterus, uterine tubes in vaults of the vagina. Thus, female internal generative organs will develop at an agenesia of gonads (see. Dysgenesis of gonads ), dysgeneses of testicles. Mezonefralny channels develop in men's internal generative organs what requires presence of gormonalnoaktivny testicles: in their absence they atrophy (irrespective of existence of an ovary). External genitals are exposed to a masculinization only under the influence of a certain level of androgens at an embryo during the period between the 12th and 20th week of an embryogenesis on condition of normal sensitivity of target tissues to them. If there is no influence of androgens, then irrespective of a genetic and gonadal floor of an embryo external genitals keep neutral (female) type of a structure.

External genitals of the hermaphrodite: incomplete masculinization (underdevelopment of a penis and failure of union of a scrotal seam, existence of a vagina).

Insufficiency of androgens at a men's embryo between the 12th and 20th week of an embryogenesis or their surplus at a female embryo is shown by an incomplete masculinization of outside genitalias, napr, an underdevelopment of a penis and failure of union of a scrotal seam (fig).

Distinguish G. true (gonadalny) and false (existence of the signs opposite to a gonadalny sex of the subject).

True G. — a rare disease. In the world literature 146 true hermaphrodites are described [Overtsir (To. Overzier), 1961].

False G. includes all forms testicular and extragenital (adrenal, medicamentous, etc.) inborn pathology of sexual development, each of which has the accurate clinical characteristic (see. Pseudohermaphroditism ).

True G., according to data of literature, is characterized by a female set of gonosomes (46 XX), various forms of a mosaic meet; a men's set of chromosomes (46 XY) meets seldom.

Morfol, germinative structures of gonads men's (seed tubules) and a female (follicles) floor can be grouped in one gonad (ovotestis). The second gonad can be same-sex (an ovary or a small egg) or also bisexual. There can be a combination of an ovary with one and a small egg on the other hand.

True hermaphrodites usually have a uterus, pipes, a vault of the vagina. In the presence of a small egg on the one hand the uterus forms odnorogy («a half of a uterus») from the remained ovary. Secondary sexual characteristics usually have elements of both floors: a low timbre of a voice, the mixed type of a figure, the mammary glands and pilosis to some extent developed on men's type.

At the vast majority of hermaphrodites of mature age an ovarian part of a gonad functionally prevails that is shown by emergence of periods.

In an ovarian part histologically find yellow bodies, and in testicular, on the contrary, the progressing hyalinosis of tubules. Conception from authentically inspected hermaphrodites in literature is not described though existence of a uterus and an ovulation as if testifies to such opportunity.

One of important to lay down. actions at G. operational sex change is. Such surgical interventions can be carried out at the corresponding age taking into account desire and the subsequent social adaptation of patients. Sex change does not cause psychological difficulties in children of 3 — 4 years.

At the age of 4 — 10 years such change is transferred hard since usually at this age consciousness of a sex is fixed, and the concept of a floor of sense of sexual function does not exist yet. Therefore it is difficult for children to explain and prove need of sex change. They are sharply negative, long keep former habits and a manner of behavior after operation (do not want to change clothes, etc.). From pubertal age children begin to realize the intersexuality and become even more vulnerable. Quite often they insist on sex determination. At youthful age (16 — 17 years) this problem becomes 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 patients at the age of 16 — 20 years have an adaptation to female change on men's psychologically happens easier, than at change men's on women's (features of male behavior are gained easier). Sex change at more advanced age is difficult for the social reasons: most of patients acquired a certain profession, social standing, etc.

At the choice of a floor consider a functional prevalence (a female or male part) of a gonad. Elements of a gonad opposite to the chosen floor, whenever possible delete, making plastic surgery of reconstruction of external genitals.

Mental disorders at a hermaphroditism

the Expressed psychoses and rough intellectual decrease are observed seldom. Intellectual development of hermaphrodites usually proceeds without essential aberrations though single descriptions of hermaphrodites with a deep oligophrenia are known (up to a deficiency of intellect and an idiocy). Observe mental immaturity (mental infantility) of these patients with childishness in behavior more often.

It is rather characteristic at G. change of the personality that, apparently, is caused not only endocrine influences, but also that situation, in a cut there are such patients. Sometimes since the early childhood at them establish the characterologic features caused by awareness of «shameful inferiority». With age such patients feel lonely and isolated from life and society. It creates favorable circumstances for emergence of the depressive reactions and suicide tendencies which are especially situationally caused.

In general sociability, softness and along with it the vigilance, shyness, sensitivity, vulnerability which are combined sometimes with not friendliness and frank hostility concerning people around are inherent to mentality of hermaphrodites.

Direct dependence between a mental warehouse and type of gonads at G. is noted. Cases when the mental warehouse and a sexual orientation changed during life at the same patient are known. Important, and sometimes and the crucial role in formation of a mental warehouse of hermaphrodites is played by conditions of education.

The psychoses arising at hermaphrodites have usually the nature of long depressions, is more rare than depressive and paranoid psychoses with nonsense of the relation and prosecution.

Treatment of the expressed mental disorders at sick G. has no differences in comparison with treatment of other mentally sick: apply antidepressants, «big» and «small» tranquilizers. In correction of changes of the personality medico-pedagogical influences are especially important.

Medicolegal value of a hermaphroditism

G.'s Examination represents one of types court. - medical researches of disputable sexual states (see. Sexual states disputable ). This examination is made under the resolution of bodies of inquiry, investigation and court. A reason for G.'s examination are the following cases: definition of the validity to military service, receipt in special educational institutions, obtaining identity documents, investigation of cases of insults and sexual crimes. G.'s examination can be appointed in connection with consideration of claims for the alimony, divorce (e.g., at impossibility of the normal sexual intercourses, lack of ability to conceive or to fertilization).

At court. - medical survey concerning G. gender of the subject is assigned on the basis of complex researches: careful collecting the specific anamnesis, general survey of a body, anthropometrical measurements, definition of character and degree of manifestation of secondary sexual characteristics, survey of external genitals, establishment of existence of gonads and their functional manifestations.

During the collecting the anamnesis it is necessary to reveal opinion the most inspected about its sex, feature of sexual inclinations and their manifestations, to establish age, in Krom came to light secondary sexual characteristics, and sexual function. Deviations in sexual desire can be connected also with sexual perversions (see).

At the general survey of osvidetelstvuyemy pay attention to a habit view and the sizes of parts of a body, a form and the size of a basin, character and deviations in a condition of secondary sexual characteristics (pilosis on a face and a body, development of mammary glands, a timbre of a voice, etc.). However data of such survey cannot in itself form the basis for the solution of a question of a sex.

At inspection of external genitals note their structure and a ratio of separate parts (topographical and in size). Dominance of men's or female type of a structure of external genitals (without their functional manifestations) also cannot form the basis of sexing. It must be kept in mind that there can be also independently existing malformations of external genitals. Allocations from generative organs have diagnostic value: semen or menstrual allocations. Lack of semen does not exclude existence of testicles since they can be underdeveloped or their secret owing to malformations can not arrive from generative organs. Males can have pseudo-menstrual allocations which, however, have no certain recurrence; at the same time at female persons the periods can be absent in connection with age, hormonal changes, diseases etc. Therefore for establishment of true nature of allocations from generative organs conduct laboratory researches.

Medical documents on treatment at urologists, obstetricians-gynecologists, about pregnancies, childbirth, abortions also promote the solution of a question of the field and sexual functions.

If necessary make repeated and commission surveys, stationary observations. In the conditions of a hospital do laboratory researches of allocations, hormonal researches, and in exceptional cases (at the obligatory consent of the examinee) and a biopsy of fabrics and punctate of gonads. At court. - a medical research of a corpse of the hermaphrodite it is necessary to conduct also the corresponding microscopic examinations.

Quite often along with sex determination at false G. the question of ability at hermaphrodites of men's type to fertilization (see) or at hermaphrodites of female type is resolved to to conception (see).

A hermaphroditism at animals

Many animals are hermaphrodites, i.e. the individual has at the same time ovaries and seed plants (simultaneous G.) or throughout life the individual makes ova, spermatozoa (consecutive G.). When G. is integral morfo-fiziol. line of a look, speak about natural G. V a typical case of G. development of both reproductive systems goes with an identical speed and the individual at the same time functions both as a male, and as a female. Such animals call true hermaphrodites, or eugermafrodita (some Castropoda mollusks, Annelidas). A part of true hermaphrodites (e.g., parasitic tape-worms) is capable to autogamy. However not autogamy, but connection of two individuals in the course of copulation is characteristic of most of them, and each individual impregnates another (earthworm). At some types of G. autogamy is interfered by development of seed plants and ovaries in different terms.

The majority of backboneless animals razdelnopolo, but in each type are available hermaphrodites. Sometimes G. is characteristic of the whole types of invertebrates: sponges, flat worms. At the same time among flukes it is necessary to specify the sort Schistosomum as representative diclinous, and in types of mollusks and annlides both G., and a razdelnopolost are equally widespread.

Both natural G., and pathological occurs among vertebrate animals. Natural G. is known only at bony fishes.

Allocate two forms of natural G. at fishes: functional, or synchronous (the functioning gonads at the same time contain both mature eggs, and sperm; autogamy, as a rule, does not happen though it also is possible), and nonfunctional (parts of a gonad function not at the same time since ovaries develop before seed plants or on the contrary; such individuals can begin to function as females, then the ovary is reduced, ovocytes rezorbirutsya and the seed plant functions). At typically diclinous fishes pathological G. which is found among sturgeon, an iridescent trout, a carp, a herring, a silver salmon, a sardine, etc. is described; in one cases men's and female gonads are developed equally, in others gonads of one of floors prevail.

Natural G. does not occur at more advanced vertebrate animals, however there is no such group of vertebrates where the phenomenon of pathological would not be observed.

Pathological G. at the highest vertebrata can be caused by two reasons. The first — existence in somatic cells of mosaic set of chromosomes that causes development of certain sexual characters (women's or men's) in different body parts. E.g., at hens and some songbirds one half of a body typically men's, and another — women's. This phenomenon is more expressed at insects (see. Gynandromorphism ). The second reason — the impact on the developing embryo of hormones of an opposite sex leading to G.'s development irrespective of the genetic constitution of parts of a body.

Biol, G.'s sense at animals in some cases is clear. E.g., autogamy at tape helminths in intestines of the person is important for preservation of a look as in an organism of the owner only the individual often lives alone.

G.'s studying at animals helps to open endocrine mechanisms of regulation of a floor. In practice these mechanisms use for regulation of a floor at page - x. animals. By influence various hormonal drugs possible to receive at a number of animals reversion of a floor up to ability of formation by the changed individuals of sex cells of an opposite sex. So, hormonal processing of eggs for an incubation gives the chance to turn male individuals in an individual women's, but only at an embryonal stage since at development of a genotype in chickens full return reversion to a male is observed. And at last, on experimental G.'s model at animals carry out testing (testing) of hormonal drugs.

Bibliography: Golubeva I. V. Adaptation of interseks to sex change, Zhurn, neuropath. and psikhiat., t * 70, century 6, page 911, 1970, bibliogr.; Liberman L. L. Inborn disturbances of sexual development, L., 1966, bibliogr.; Savchenko H. E. Gipospadiya and hermaphroditism, Minsk, 1974, bibliogr.; With t and r to about in a H. T. Fundamentals of clinical andrology, M., 1973; Teter E. Hormonal disturbances at men and women, the lane with polsk., Warsaw, 1968; In about with z k about 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.

And. B. Golubeva; E. 3. Bronstein (court.), D. D. Orlovskaya (loony.), D. V. Ponov (biol.).