Intersex Surgery - Controversies and Unsettled Questions

Controversies and Unsettled Questions

Management practices for several types of intersex conditions and other abnormalities and injuries of the genitalia have evolved over the last 50 years. In the last decade several of the surgical practices have become the subject of public and professional controversy. See History of intersex surgery for more detail.

Is functional outcome better when surgery is performed in infancy, in adolescence, or adulthood, for vaginoplasty for markedly virilized females (e.g., from congenital adrenal hyperplasia, mixed gonadal dysgenesis, or partial androgen insensitivity)?

• Argued or putative advantages of infant surgery
  • Tissue is more elastic and heals better according to many surgeons.
  • Genital surgery performed before the age of memory is less emotionally traumatic.
  • Surgery in infancy avoids asking adolescent to make a decision that is stressful and difficult even for adults.
  • Assuming infant surgery is successful, there is no barrier to engaging in normal sexual activities, and less distortion of psychosexual identity.
• Argued or putative advantages of surgery in adolescence or later
  • If outcome is less than satisfactory, early surgery leaves a person wondering if she would have been better off without it.
  • Any surgery not absolutely necessary for physical health should be postponed until the person is old enough to give informed consent; parents should not be empowered to make medical decisions for their children.
  • Genital surgery should be handled differently than other birth defect surgery; this is the one type of surgery that parents should not be empowered to make decisions about because they will be under social pressure to make "bad" decisions.
  • By mid-adolescence or later, a woman may decide that her abnormal genitalia do not need to be changed.
  • Infant vaginoplasties should not be done because most women who have had them performed report some degree of difficulty with sexual function; even though we have no evidence that adult sexual function will be better if surgery is deferred, the outcomes couldn't be worse than they currently are after infant surgery.

Do any advantages of infant clitoral reduction surgery outweigh the potential disadvantages of reduced or distorted sexual sensation? Clitoral reduction is rarely done except in combination with vaginoplasty when substantial virilization is present.

• How much weight should be given to the cosmetic argument that there is value in making it more normal looking? See for example the letters following Melton, 2001.

Should parents have the same ethical and legal right to consent on behalf of their child to genital surgery as to consent to other reconstructive surgery (e.g., cleft lip repair or birth mark removal) for largely psychosocial purposes?

• The high court in Colombia has ruled no, and some advocacy groups in the US and elsewhere agree (, comparing this type of surgery to genital mutilation(intactivism).

How can we minimize gender identity problems? Is it valid to assume in cases of ambiguous genitalia that the magnitude of the "innate" tendency to develop a specific gender identity is usually similar to the degree of genital virilization? Should we abandon completely the idea that an unambiguous XY child with an irreparably defective penis might be better off raised as a girl?

• Medical professionals have traditionally considered the worst outcomes after genital reconstruction in infancy to occur when the person develops a gender identity discordant with the sex assigned as an infant. Most of the cases in which a child or adult has voluntarily changed sex and rejected sex of assignment and rearing have occurred in partially or completely virilized genetic males who were reassigned and raised as females. This is the management practice that has been most thoroughly undermined in the last decade, as a result of a small number of spontaneous self-reassignments back to male in a number of genetic males who had been raised as female because of birth defects of the penis which did not involve undervirilization (e.g., exstrophy or traumatic loss).
• Reducing the likelihood of a gender "mismatch" is also a claimed advantage of deferring reconstructive surgery until the patient is old enough to assess gender identity with confidence.
• However, support groups tend to identify intense feelings of shame and betrayal as the worst outcomes of a philosophy of management that focuses on normalizing the child's anatomy. Many individuals who have developed a discordant gender identity and rejected the sex assigned during infancy have done quite well after transition (Reiner 2004, Consortium 2006, ). Gender identity may not be the most important variable to consider in caring for children with intersex conditions.

Within the last decade, some people have raised the question of whether surgery to correct abnormal genitalia should be done at all, especially for purposes of changing appearance. Opponents of all "corrective surgery" on abnormal genitalia suggest we should be attempting to change social opinion regarding the desirability of having genitalia that look more average, rather than performing surgery to try to make them more like other peoples'.

Historical background, supporting arguments, and changing practice standards are treated in more detail in History of intersex surgery, and in some of the following references (Creighton, 2001).