History of intersex surgery
[6] Paul of Aegina (c. 625 – c. 690), quoting Leonidas (Alexandria, 2nd – 3rd centuries), describes in section LXIX (On Hermaphrodites) of his sixth book four types of intersex and how to "cure" three of them by surgically removing the "useless parts".
[8] In 1779, in England, a seven-year-old intersex child, initially assigned female, underwent the first recorded surgery during modern times, resulting in their reassignment as male.
[9][10] In the United States genital reconstructive surgery was pioneered between 1930 and 1960 by urologist Hugh Hampton Young and other surgeons at Johns Hopkins Hospital in Baltimore and other major university centers.
Demand for surgery increased dramatically with better understanding of the condition congenital adrenal hyperplasia (CAH) and availability of a new treatment (cortisone) by Lawson Wilkins, Frederick Bartter and others around 1950.
[12] Hormone assays and karyotyping to ascertain sex chromosomes, and the availability of testosterone for treatment led to partial understanding of androgen insensitivity syndrome.
As the number of children with intersex conditions referred to Lawson Wilkins' new pediatric endocrinology clinic at Hopkins increased, it was recognized that doctors "couldn't tell by looking" at the external genitalia, and many errors of diagnosis based on outward appearance had led to anomalous sex assignments.
The most common intersex surgery offered in childhood was amputation of the clitoris and widening of the vaginal opening to make the genitals of a girl with CAH appear more conformed to the expectations.
Earlier correction reduced the social "differentness" of a child with a cleft lip, or club foot, or skull malformation, or could save the life of an infant with spina bifida.
Genital corrective surgeries in infancy were justified by (1) the belief that genital surgery is less emotionally traumatic if performed before the age of long-term memory, (2) the assumption that a firm gender identity would be best supported by genitalia that "looked the part," (3) the preference of parents for an "early fix," and (4) the observation of many surgeons that connective tissue, skin, and organs of infants heal faster, with less scarring than those of adolescents and adults.
In this context, enhancing the ability of people born with abnormalities of the genitalia to engage in "normal" heterosexual intercourse as adults assumed increasing importance as a goal of medical management.
[13][14] By 1970, surgeons still considered it easier to "dig a hole" than "build a pole",[15][16] but had abandoned "barbaric" clitorectomies in favor of "nerve sparing" clitoral recession and promised orgasms when the girls grew up.
In 1972 John Money published his influential text[18] on the development of gender identity, and reported successful reassignment at age 22 months of a boy (David Reimer) who had lost his penis to a surgical accident.
[citation needed] In the 1980s research in both animals and humans began to provide evidence that sex hormones play an important role in early life in promoting or constraining adult sex-dimorphic sexual behavior and even gender identity.
[31] Some clinicians proposed a moratorium on pediatric sex reassignment, particularly of undervirilized males as females, due to a lack of data that rearing or appearance of genitalia play a major part in gender identity development.
[37]In 2006, an invited group of clinicians met in Chicago and reviewed clinical evidence and protocols, argued that and adopted a new term for intersex conditions: "Disorders of sex development" (DSD).
"[38] The term has been controversial and not widely adopted outside clinical settings: the World Health Organization and many medical journals still refer to intersex traits or conditions.
[39] Academics like Georgiann Davis and Morgan Holmes, and clinical psychologists like Tiger Devore argue that the term DSD was designed to "reinstitutionalise" medical authority over intersex bodies.
... information across a range of assessments is insufficient ... outcomes from clitoroplasty identify problems related to decreased sexual sensitivity, loss of clitoral tissue, and cosmetic issues ... Feminising as opposed to masculinising genitoplasty requires less surgery to achieve an acceptable outcome and results in fewer urological difficulties... Long term data on sexual function and quality of life among those assigned female as well as male show great variability.
[44] Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and "recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences".
Participating children reported significant disturbances, especially within family life and physical well-being – these are areas that the medical and surgical treatment was supposed to stabilize.
[46]A 2016 Australian study of persons born with atypical sex characteristics found that "strong evidence suggesting a pattern of institutionalised shaming and coercive treatment of people".
[47] A 2016 follow-up to the 2006 Consensus Statement, termed a Global Disorders of Sex Development Update stated, There is still no consensual attitude regarding indications, timing, procedure and evaluation of outcome of DSD surgery.
There is no evidence regarding the impact of surgically treated or non-treated DSDs during childhood for the individual, the parents, society or the risk of stigmatization... Physicians working with these families should be aware that the trend in recent years has been for legal and human rights bodies to increasingly emphasize preserving patient autonomy.
