We present a case of a 13-year-old Filipino patient with ambiguous genitalia, randomly assigned as female at birth and was subsequently reared as such. Starting at 10 years of age, secondary male sexual characteristics emerged. However, medical consultation was sought only when the patient developed a gradually enlarging and painful abdominal mass. After cytogenetic studies, we are able to identify the case as Disorder of Sex Development, 45,X/46,X,der(Y) mosaicism, mixed gonadal dysgenesis. Further imaging, laparotomy and histopathology, revealed that the abdomino-pelvic mass was from the right ovary, composed of immature teratoma. Ductus deferens and epididymis were also identified within the right ovary. At the time of presentation, the patient was already experiencing gender dysphoria. This report not only highlights the wide spectrum of phenotypes in mixed gonadal dysgenesis, but also stresses the importance of proper gender assignment during the newborn period in patients with disorders of sex development.

Key Words: disorder of sexual development, ambiguous genitalia, mixed gonadal dysgenesis, mosaicism, 45,X/46,X,der(Y) karyotype, immature teratoma, gender dysphoria

Background and Objective: Primary care providers are key players in providing quality care to patients and advancing Universal Health Care (UHC). However, effective and quality healthcare delivery may be affected by inadequate knowledge and failure to adhere to evidence-based guidelines among providers. The Philippine Primary Care Studies (PPCS) is a five-year program that pilot tested interventions aimed at strengthening the primary care system in the country. Evidence-based training modules for healthcare providers were administered in Sorsogon and Bataan from the years 2018 to 2021. Module topics were selected based on common health conditions encountered by providers in rural and remote settings. This program aimed to evaluate the effectiveness of training in increasing provider knowledge. Methods: A series of training workshops were conducted among 184 remote- and 210 rural-based primary care providers [nurses, midwives, barangay or village health workers (BHWs)]. They covered four modules: essential intrapartum and newborn care (EINC), integrated management of childhood illness (IMCI), non-communicable diseases (NCD), and geriatrics. A decision support system (UpToDate) was provided as a supplementary resource for all participants. We administered pre-tests and post-tests consisting of multiple-choice questions on common health conditions. Data was analyzed using paired one-tailed t-test, with an alpha of 0.05. Results: The knowledge of nurses, midwives, and BHWs improved after the training workshops were conducted. The largest increase from pre-test to post-test scores were observed among the midwives, with a mean difference (MD) of 32.9% (95% CI 23.9 to 41.9) on the EINC module, MD of 25.0% (95% CI 16.6 to 33.4) in the geriatrics module, and MD of 13.5% (95% CI 6.9 to 20.1) in the NCDs module. The nurses had the greatest improvement in the IMCI module (MD 10.8%, 95% CI 2.5 to 19.1). The knowledge of BHWs improved in all participated modules, with greatest improvement in the NCD module (MD 9.0%, 95% CI 5.77 to 12.14). Conclusions Primary care workshops, even if conducted as single-sessions and on a short-term basis, are effective in improving short-term knowledge of providers. However, this may not translate to long-term knowledge and application in practice. Furthermore, comparisons across provider categories cannot be made as participant composition for each training workshop varied. Ultimately, this study shows enhancing provider knowledge and competence in primary care will therefore require regular and diverse learning interventions and access to clinical decision support tools.
Capacity Building ; Health Workforce ; Philippines ; Primary Health Care