American Journal of Medical Genetics 90:25–28 (2000)
SRY Gene Transferred to the Long Arm of the
X Chromosome in a Y-Positive XX
True Hermaphrodite
Ester Margarit,1* M. Dolors Coll,2 Rafael Oliva,1 David Gómez,1 Anna Soler,1 and
Francisca Ballesta,1
1
Servei de Genètica Hospital Clı́nic de Barcelona, Barcelona, Spain
2
Departamento de Biologia Cel⭈lular i Fisiologia Animal Facultad de Ciències Universitat Autònoma de Barcelona,
Barcelona, Spain
Yp-specific sequences, including the testicu-
lar determinant gene SRY, have been de-
tected and located in a 46,XX true hermaph-
rodite individual, using PCR amplification
and fluorescent in situ hybridization
(FISH). Among different Y chromosome loci
tested, it was only possible to detect Yp se-
quences. The Y-centromere and Yq se-
quences were absent. Unexpectedly, the Y
fragment was translocated to the long arm
of one of the X chromosomes, at the Xq28
level, and the derivative (X) chromosome of
the patient lacked q-telomeric sequences.
To our knowledge, this is the first Yp/Xq
translocation reported. The coexistence of
testicular and ovarian tissue in the patient
may have arisen by differential inactivation
of the Y-bearing X chromosome, in which Xq
telomeric sequences are missing. The pos-
sible origin of the Yp/Xq translocation, dur-
ing paternal meiosis or in somatic paternal
cells, is discussed. Am. J. Med. Genet. 90:25–
28, 2000. © 2000 Wiley-Liss, Inc.
KEY WORDS: SRY gene; true hermaphro-
ditism; sex determination;
X;Y translocation; X-inactiva-
tion
INTRODUCTION
True hermaphroditism is defined by the coexistence
of testicular and ovarian tissue in the same individual
[Van Niekerk and Retief, 1981]. External genitalia in
these individuals are often abnormal, with different
levels of ambiguity depending on the rate of testicular
*Correspondence to: Ester Margarit, Ph.D. Genetics Service,
Hospital Clinic de Barcelona. Villarroel, 170/08036-Barcelona,
Spain. E-mail: margarit@clinic.ub.es
Received 2 March 1999; Accepted 2 September 1999
© 2000 Wiley-Liss, Inc.
development. Most XX true hermaphrodites are nega-
tive for Y sequences. The partial testicular differentia-
tion in these individuals, as in Y-negative XX males,
can be presumably due to defects in autosomic or X-
linked genes involved in the sexual differentiation.
Among the Y-positive true hermaphrodites, 6 cases
have been studied by in situ hybridization (ISH), de-
tecting the Y-chromosome fragment in Xp22 [Fechner
et al., 1994; Kusz et al., 1999; McElreavey et al., 1992].
An unequal interchange between the pseudoautosomal
regions of Xp and Yp chromosomes (PAR1) has proved
to be the cause of the transfer of Yp sequences to the X
chromosome during paternal meiosis [Ferguson-Smith,
1966]. As the Y fragment includes the testicular deter-
mining gene SRY, individuals with the Y-bearing X
chromosome develop as males, originating the well-
defined syndrome of XX males [De la Chapelle, 1981].
However, some XX males have incomplete testicular
differentiation and sexual ambiguities. Two mecha-
nisms, non-random and random inactivation of the Y-
bearing chromosome, have been proposed to explain
the partial testicular differentiation present in some
Y-positive XX males and true hermaphrodites [Fechner
et al., 1994; Ferguson-Smith, 1966]. In this article, we
report the first case of an XX true hermaphrodite with
Yp sequences, including the SRY gene, transferred to
the long arm of the X chromosome.
CLINICAL REPORT
The female patient, age 34, was referred to our Ge-
netics Service for genetic studies and counseling. Stat-
ure and weight were 180 cm and 78 kg, respectively. At
birth, the patient presented male external genitalia
with hypospadias and was reared as a boy during the
first 2 years. However, the presence of sexual ambigu-
ities led to a cytogenetic study, which showed a 46,XX
karyotype. Subsequently, a change of sex was decided,
and the male external genitalia were removed. When
the patient reached the 17 years, a vulvovaginoplasty
was performed, and she started to receive hormonal
26 Margarit et al.

Fig. 1. FISH detection of Yp sequences transferred to Xq. Both X centromeres are labeled in green by an alpha-satellite probe, and the Yp fragment
is labeled in the same color by a Y-specific painting probe.

medication in order to induce regular menses. Seven
years later, the patient had an operation because of
endometrioma on the right ovary and Fallopian tube.
At 31 years, the patient presented with urethrohydro-
nephrosis and cysts on the left gonad. After removal,
the histological study of the left gonad showed the pres-
ence of an ovotestis with fibrous ovarian stroma, sem-
iniferous tubules without germ cells, rete testis, and
Leydig cells.
MOLECULAR ANALYSIS
PCR analysis was performed on leukocyte DNA of
the patient by using different STS (sequence-tagged

Fig. 2. FISH analysis using telomere-specific probes for the X and Y chromosomes. Short-arm probes (Xp and Yp) are labeled in green, and the
long-arm probes (Xq and Yq) are labeled in red. Note the presence of one normal X chromosome containing the Xp (green) and the Xq (red) telomeres;
and one derivative (X) chromosome containing Xp and Yp telomeres (both in green).
 SRY Gene in Xq in an XX True Hermaphrodite
sites) for the Y chromosome: PAB, SRY, Y53, sY274,
sY238, sY59 (Yp), sY78 (Y centromere), and sY130
(Yq). The position along the Y chromosome, conditions
of amplification, and size of amplification products of
these STS have been reported previously [Margarit et
al., 1998].
CYTOGENETIC AND FISH ANALYSES
FISH analysis was performed on metaphase chro-
mosomes using Spectrum CEP威 alpha-satellite probes
for X and Y chromosomes and a WCP威 painting probe
for the Y chromosome, labeled with the Spec-
trumGreen™ fluorochrome (Vysis). Conditions of hy-
bridization have been described previously [Margarit
et al., 1998]. A subsequent FISH analysis was per-
formed using telomeric probes specific for sex chromo-
somes, following the manufacturer’s indications (Chro-
moprobe威-T, Cytocell, UK).
An additional cytogenetic study was performed after
FISH analysis in order to detect the Y sequences pre-
sent on the X chromosome. Using GAG banding, the
study was done by standard procedures from lympho-
cyte chromosomes of the patient.
RESULTS
By PCR, most of the Yp loci tested were found to be
present in the patient’s DNA: PABY, SRY, Y53, sY274
(RPS4Y), and sY238 (ZFY). The STSs sY59 (Yp11.3),
sY78 (centromere), and sY130 (Yq) did not show any
amplification, indicating the absence of these se-
quences in the patient. Therefore, the Y breakpoint
must lie on the Yp11.3 cytogenetic band. By FISH
analysis, the Yp fragment was found on the long arm of
one of the X chromosomes (Fig. 1). The FISH analysis
using specific probes for X and Y telomeres showed a
derivative X chromosome with Xp and Yp telomeric
sequences (Fig. 2). Using cytogenetic analysis, it was
possible to detect a small G-positive extra band at the
distal long arm of the X chromosome, at the Xq28 level
(Fig. 3).
Based on the molecular, FISH, and cytogenetic
analyses, the interpretation of the Yp/Xq translocation
is the one represented in Figure 3, and the karyotype of
the patient can be redefined as 46,XX,add(X)(q28).ish
der(X),t(X;Y)(q28;p11.31).
DISCUSSION
In this work, we report the first case of an XX true
hermaphrodite with Yp sequences, including the SRY
gene, transferred to Xq (see the review of Hsu, 1994).
Testicular development in an XX individual can be ex-
plained by the presence of Y-chromosome sequences,
either in a hidden XY cell line [Miró et al., 1978] or by
translocation of these Y sequences to another chromo-
some. Numerous XX males have been characterized by
the presence of a Yp fragment transferred to Xp22
[Andersson et al., 1986; Magenis et al., 1987; Margarit
et al., 1998]. This Y fragment includes the testicular
determinant gene SRY, giving maleness to XX indi-
viduals [Rego et al., 1996]. Interestingly, the same Xp/
Yp translocation has been found in 3 XX true hermaph-
27
Fig. 3. Cytogenetic detection of a G-positive extra band at Xq (A) and
interpretation of the Yp/Xq interchange, originating the Y-bearing X chro-
mosome detected in the patient (B).
rodite patients [Berkovitz et al., 1992; McElreavey et
al., 1992]. In these cases, incomplete testicular devel-
opment originated the presence of Wolffian and Mülle-
rian-derived structures in the same individual. The dif-
ferent phenotypes of XX males and true hermaphro-
dites who are carriers of the same translocation has
been explained by a different pattern of inactivation of
the Y-bearing X chromosomes [Fechner et al., 1994]. In
the case reported here, FISH and cytogenetic analyses
have demonstrated that the Y sequences are located at
the Xq28 level, a region with homology to Yq called the
pseudoautosomal region 2 (PAR2).
The patient must have inherited the SRY-bearing X
chromosome. Although theoretically possible, it is un-
likely for the patient’s mother to be a carrier of the
derivative X chromosome, considering her normal phe-
notype and fertility. The transfer of Y sequences to the
X chromosome must have originated in the patient’s
father, either affecting all paternal cells or only the
germinal line. Because the patient’s father is deceased,
we cannot determine whether he was a carrier of the
X/Y balanced translocation. However, this possibility is
unlikely if we consider that the lack of normal recom-
bination between the PAR1 regions of the sexual chro-
mosomes during paternal meiosis would have caused
infertility. This is not the case, because the true her-
maphrodite patient has 3 sisters and 5 brothers, all of
them with a normal phenotype.
Accepting that the X/Y translocation arose during
paternal meiosis, the mechanism through which Yp
has been transferred to Xq is intriguing, because there
is no apparent homology between Yp11 and Xq28 se-
quences [Vogt et al., 1997]. It would be possible that an
illegitimate recombination between the Y-PAR1 and
the X-PAR2 produced the interchange. Another possi-
28 Margarit et al.
bility could be the presence of a pericentric inversion in
the parental Y chromosome. This inversion could give
rise to an atypical meiotic interchange Xq/Yp, resulting
in the transfer of the SRY gene to the X chromosome, as
it occurs in XX males. Unfortunately, the family of the
patient refused further studies to test this possibility.
Alternatively, the translocation may have originated at
a different stage during the differentiation of the pa-
ternal germinal cells.
In conclusion, this is the first reported individual
with the SRY gene transferred to the long arm of the X
chromosome. The derivative X chromosome in the pa-
tient may have originated through a paternal
Xq28;Yp11.3 translocation, probably in the germinal
line. This derivative (X) is a carrier of extra Y material,
including the SRY gene, and lacks some X sequences,
including the q-telomere. The deletion of Xq28 se-
quences may have predisposed the derivative (X) to be
inactivated in most of the patient’s cells, leading to the
SRY gene inactivation and, subsequently, to hermaph-
roditism due to incomplete testicular differentiation.
We stress the usefulness of FISH studies in order to
locate the Y sequences detected in molecular analyses.
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