The Endless Quest for Sex Determination Genes
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Clin Genet 2004: 67: 15–25 Copyright # Blackwell Munksgaard 2004 Printed in Singapore. All rights reserved CLINICAL GENETICS doi: 10.1111/j.1399-0004.2004.00376.x Developmental Biology The endless quest for sex determination genes a a,b,c Fleming A, Vilain E. The endless quest for sex determination genes. A Fleming and E Vilain Clin Genet 2004: 67: 15–25. # Blackwell Munksgaard, 2004 aDepartment of Human Genetics, bDepartment of Pediatrics, and Disorders in human sex determination cause defects in gonadal function cDepartment of Urology, David Geffen and can result in a spectrum of abnormalities in the internal and external School of Medicine at UCLA, Los genitalia, ranging from relatively mild sexual ambiguities to complete Angeles, CA, USA sex reversal. Several genes involved in sex determination have been Key words: sex determination – gonadal validated in humans, and activities of their gene products are being dysgenesis – gonads – development – elucidated, particularly in mouse models. However, how these genes sexual ambiguity – genetics interact in an overall process remains far from clear, and it is probable Corresponding author: Eric Vilain, MD, that many additional genes are involved. Management of patients with PhD, Departments of Human Genetics pathologies in sex determination and subsequent differentiation is and Pediatrics, UCLA School of currently under debate, but will require not only an understanding of the Medicine, Gonda Center, Suite 6357, 695 multiple definitions of an individual’s sex but also an increased Charles Young Drive South, Los Angeles, knowledge of the molecular mechanisms involved in sex determination. CA 90095-7088, USA. Tel.: þ1 310 267 2455; fax: þ1 310 794 5446; e-mail: [email protected] Received 23 September 2004, revised and accepted for publication 23 September 2004 Defining an individual’s sex is not simple. Geno- regress and Mu¨llerian ducts become the upper typic sex refers to genetic make-up, where males part of the vagina, uterus, and Fallopian tubes. (typically 46,XY) or females (46,XX) are defined Pathologies of sexual development are quite by presence or absence of a Y chromosome (1). varied in humans. Sex differentiation pathologies Phenotypic sex is characterized by the primary and are relatively common (about one in 100) and secondary sex characteristics of an individual. Sex- better understood than those of sex determin- ual identity includes a person’s sense of self (gender ation. Here, gonads develop normally, but defects identity) and his/her attraction to others. These in subsequent gene and/or hormone function aspects of sex are not always in concordance in a result in abnormalities of the internal or external given individual, and consideration of all three genitalia, with a wide range of type and severity. aspects is critical and complex – and currently the These abnormalities are usually variations on the subject of much debate – in the clinical setting. norm, such as a small penis, undescended testes Physiological sexual development includes both (cryptorchidism), an enlarged clitoris, or abnor- sex determination and sex differentiation, a some- mal positioning of the urethral opening (hypo- what arbitrary but useful distinction. In mam- spadias). Some, however, are severe enough to mals, gonads are indistinguishable (indifferent) be termed sexual ambiguities. early in their development; sex determination – Sex determination pathologies are compara- the decision to develop as testes or ovaries – tively rare (estimated at one in 20,000). They begins midway through gonadogenesis and ends result from duplications, mutations, or deletions with formation of the gonads. Sex differentiation of sex-determining genes and involve abnormal follows in accordance: in males, testicular hor- gonadal development (dysgenesis) and, typically, mones cause the regression of Mu¨llerian ducts a discrepancy between genotypic and phenotypic and development of Wolffian ducts into the epi- sex. XX males often have small, azoospermic didymis, vas deferens and seminiferous tubules, testes, normal male genitalia, and no Mu¨llerian- and testicular descent; in females, Wolffian ducts derived structures, but can also have hypospadias 15 Fleming and Vilain or sexual ambiguity. XX true hermaphrodites have default state must have a molecular basis has gonads with both testicular and ovarian tissue, spurred research to explore female mechanisms ambiguous genitalia with persistence of some as well. Finally, because clinical management Mu¨llerian structures. XY females with complete does not always fall easily into the categories out- or pure gonadal dysgenesis have fibrous (streak) lined above, we also include figures (Figs 1 and 2) gonads and normal female genitalia, including a that summarize the major disorders of sexual uterus. XY females with partial dysgenesis may development, including both determination and have sexual ambiguities. Although the focus of differentiation. much research, these pathologies are not yet well understood and can be difficult to diagnose. Genes involved in testis development Here, we present information about each of SRY the genes known to be involved in human sex determination (Table 1). Although many genes Around the early 1990s, a series of elegant experi- involved in sex determination have been identi- ments found SRY to be the once elusive mamma- fied in animal models, their functions are not yet lian testis-determining gene. Positional cloning fully understood, and the majority of those genes located a 35-kb fragment of the Y chromosome have not been validated in humans. Male- translocated onto the X chromosome of XX male determining genes have been more thoroughly and true hermaphrodite patients (3, 4); sequence studied to date, perhaps an outgrowth of Jost’s analysis and gene mapping defined a conserved experiments in the 1940s (2) that showed testis sequence – SRY – within that fragment (5, 6). determination to be synonymous with sex deter- Murine Sry gene expression profiles revealed a mination, leaving ovarian determination to be the male-specific increase in transcript consistent default state. Recently, understanding that even a with earliest divergence of male and female Table 1. Known genes involved in sex determination (2, 3) Validated Gain-of-function Gene in humans Human locus Putative function Loss-of-function phenotype phenotype Testis determining SRY X Yp11.3 Transcription factor XY female (human, mouse) XX male (human, mouse) SOX9 X 17q24 Transcription factor XY female þ campomelic XX male dysplasia (human) (human, mouse) SF1 X 9q33 Transcription factor XY female þ adrenal insufficiency (human); genital and adrenal developmental blockage (KO) WT1 X 11p13 Transcription factor XY female þ kidney defects, Wilms’ tumor (human); absent gonads, blockage in kidney and adrenal development (KO) DAX1 X Xp21.3 Transcription factor Adrenal hypoplasia congenita; XY female hypogonadism (human); (human, mouse) spermatogenesis block (mouse) DMRT1 X 9p24.3 Transcription factor XY female (human)a; postnatal loss of Sertoli and germ cells (KO) ATRX X Xq13.3 Transcription factor XY female þ mental retardation, a-thalassemia (human) M33 17q25 Transcription factor XY female, Sox9 reduced (KO) FGF9 13q11–13 Signaling molecule XY female (variable phenotype) þ lung defects (KO) Ovary determining WNT4 X 1p35 Signaling molecule XX testosterone XY female synthesis þ Wolffian duct (human) development (mice) FOXL2 Xb 3q23 Transcription factor Premature ovarian failure þ BPES (humans); XX male (goats) KO, mouse knock out; BPES, Blepharophimosis Ptosis Epicanthus Inversus Syndrome. aDMRT1 is one gene in a large sex-reversing deletion. bNot validated for sex reversal in humans. 16 Sex determination genes Fig. 1. Simplifieddiagnosticflowchart of the major disorders of sexual development in feminized boys. gonadal development (7, 8). XX and XYpos are not yet clear, but several factors have been (a weak allele of Sry tending to sex reverse on a implicated, including SP1, WT1, SF1, GATA4, C57BL/6 background) mice transgenic for a FOG2 (12), and three members of the insulin 14-kb fragment containing Sry developed testes receptor tyrosine kinase family (19). (9, 10). Deletions and mutations in SRY/Sry Despite certainty that SRY is the testis- often result in XY female sex reversal [in mice: determining gene, it is still not known what (11) and (6); in humans: reviewed in (12)]. downstream targets SRY regulates and whether SRY, a single-exon gene on the Y chromosome, it acts as an activator or repressor (20), although is an apparent transcription factor (13). Its gene it is widely thought to up-regulate SOX9 expres- product contains a conserved High Mobility sion. In addition, sequence analysis of SRY does Group (HMG) motif that binds and bends its not explain all pathologies of sex determination. target DNA (14) and is flanked by two nuclear Genetic studies have shown that SRY is not localization signals (NLSs) (15). Almost all sex- detected in 8% of unambiguous XX males, 91% reversing mutations in SRY are found in the of XX males with sexual ambiguities, and 84% of HMG/NLS domain (12) and affect its DNA- XX true hermaphrodites (21), and that mutations binding affinity (13), its binding/bending of target in the SRY gene have been found in only 15% of DNA (16), or its nuclear localization (17, 18). The XY females (12). These data indicate that add- precise mechanisms regulating expression of SRY itional genes are involved in testis determination. Fig. 2. Simplifieddiagnosticflowchart