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Surgical Sex Reassignment Should Not Be Done At Birth

Surgical Sex Reassignment Should Not Be Done At Birth

Surgical Sex Reassignment Should not be Done at Birth

All around the country newborns are being bundled up and rushed from the delivery room with little or no explanation given to the parents. These parents are often given very little information about their baby's condition or the procedure known as surgical sex reassignment that will be done on their infant. Since 1910 doctors and parents have been reluctant to accept a child born with anything other than normal male or female genitals. Children born that do not fit the mold of normal are surgically altered to resemble the sex the doctor thinks the child should be. (Dreger) Most doctors practicing in the field of pediatric surgery and pediatric endocrinology feel that a child can not function in life without normally developed genitals. (Lehrman) This belief is based upon the 1955 theory of John Money of Johns Hopkins University that children are psychosexually neutral at birth. Money believed that differentiation occurred as a result of experiences growing up. (Hettena) As recently as 1998 research supported Money's theory that gender identity developed after birth. As a result doctors practicing in these fields have performed thousands of sex reassignment surgeries in the United States since the 1960's. An article written in 1997 by Dr. Milton Diamond from the University of Hawaii detailed the failure of a sex reassignment surgery performed by Dr. Money. (Kipnis) This, coupled with the recent establishment of a group called the Intersex Society of North America, has caused the medical community to question their practices regarding sex reassignment. As follow up is being done on patients who have undergone sex reassignment surgery, many tragic results are being uncovered. Although most of us think of sex in terms of male and female, the medical community has classified another group as intersexed. Intersexed people are all the people who don't quite fit the mold of male or female. Some are simply underdeveloped and actually appear to fall somewhere between male and female. Intersex is defined as "A sexual intermediate individual that has developed as a male (or female) up to a certain point in its life-history and thereafter has continued its development as a female (or male). Owing to the suppression of one type of sex tendencies by the other, intersexuals usually show a mixture of male and female parts and are almost invariably sterile." (Diamond) The variations from what many doctors consider the male and female mold are many and include the following: small or micro penis (less than 1 inch), undescended testes, an enlarged clitoris (more than 3/8 of an inch), absence of a vagina, or the presence of both a penis and a vagina. These conditions are referred to as ambiguous genitalia. This happens during the eighth week of fetal development, when the sexual organs begin to develop. (Diamond) In some cases the sex can be determined by a biopsy of the gonadal tissue. If it can be determined that the gonads are made up of ovarian or testicular tissue the determination of the baby's sex is sometimes made at this time. Cases of intersexed children are one in two thousand in North America.

Further attempts to determine a baby's sex include chromosome tests. If the chromosome type shows normal XX (female) or XY (male) chromosomes then this is used in the determination of the baby's sex. The problem lies with the babies that appear to be either male or female yet have gonadal tissue of the opposite sex or chromotype of the opposite sex. A condition called congenital adrenal hyperplasia (CAH) causes some XX female fetuses to develop male-like external genitalia. Their adrenal glands produce large amounts of androgens. These children will sometimes menstruate through the penis after puberty. A second condition called androgen insensitivity syndrome (AIS) causes XY male fetuses to develop female external genitalia. Their normal testes produce androgens but, because of a cellular abnormality that partially or completely inhibits response to the hormone, male development is unaffected and proceeds toward a female external development at birth. It has been found that chromosomes occur in several other combinations besides just XX (female) and XY (male) combination. Other chromotypes that have been found include XXX, XXY, XXYY, and XXXYY. (Lehrman) The additional chromosomes cause the female reproductive organs to be over masculinized or the male organs to be under masculinized. (Diamond) This can make it nearly impossible to determine the sex of a child. In rare cases a variation of the male XY chromosome produces hypospadias, where the penis is open at some location other than at the end. Some children are even found to have two different chromotypes in different cells of the body. In these cases the doctors must make a decision about how to label the gender of the child. This decision has to be made quickly before the birth is announced to family and friends.

The procedure of surgical reassignment of sex on infants has come under heavy scrutiny. Pediatricians caring for infants with ambiguous genitalia inferred that genetic makeup and prenatal endocrinology could largely be ignored in the assignment of sex. They reasoned that the penis had to be plainly absent or present from infancy on, and that these children had to be raised as girls or boys with no hint of ambiguity. Accordingly, pediatric surgeons strive to benefit these patients by "normalizing" ambiguous genitalia. This included reducing enlarged clitoris (eliminating visible penis-like structures in babies assigned as females) and, because of the technical difficulty creating functional and cosmetically believable male genitals, refashioning ambiguous male genitalia as female. It has been a standard pediatric practice to recommend surgery for infants with ambiguous genitalia. Parents are told to raise their children without ambiguity. The pediatric community holds that the reassignment surgery must be completed no later than age 18 to 24 months. In the early 1950's, Dr. Money and his colleagues developed guidelines of psychosexual management for infants born with physical intersex conditions. Their intent was to guide physicians and other health professionals in making decisions about sex assignment and rearing. These guidelines included the following:

1) Sex assignment should be to the sex that shows the best prognosis for reproductive function, sexual function, normal-looking external genitalia and physical appearance, and a stable gender identity;

2) The decision should be made as early in the infancy period as possible;

3) There should be minimal ambiguity on the part of the parents about the sex assignment in regards to child rearing. (Bradley)

Money's theory is that children with ambiguous genitalia have shown that sexual identity is a function of social learning through differential responses of multiple individuals in the environment. For example, children whose genetic sexes are not clearly reflected in external genitalia (i.e., hermaphrodites) can be raised successfully as members of either sex if the process begins before the age of two years. Therefore, a person's sexual body image is largely a function of socialization. This theory quickly became standard practice in pediatrics nationwide.

Physical side effects of reassignment surgery include sterility and lack of erotic function or stimulation. Efforts have been made to preserve the reproduction ability if at all possible, however sterility is usually the result of surgical sex reassignment. With the sexual assignment to a female, unless there are both male and female organs nearly fully developed, there is little that can be done to provide stimulation and sensation. In many cases only a cavity is made and a normal looking vaginal opening is constructed. Outwardly the child looks female but internally there is nothing but an opening. To date a functional penis cannot be constructed. A constructed penis would be nothing more than a urinary extension at best, without the ability for erection. Studies have shown that male children born with a less than 1 inch penis, that would have been reassigned female, have normal sexual lives without the surgery. A study of 20 males who had not been surgically assigned at birth to female has had profound results: 12 were postpubertal 17 to 43 years old. While 6 of these dozen admitted to being teased about a small penis, all 20 patients "felt male," and all had erections and orgasms. Nine had sexual intercourse satisfactory to themselves and their partners; seven were married and still others were experiencing sexual activity. One had fathered a child. (Diamond)

Serious psychological side effects have been found in patients that have undergone this surgery. Many parents of children born with male genitalia and reassigned female at birth report that their children exhibit male traits as opposed to female traits. As early as age 5, some of these children state that they are boys not girls. Children that have undergone the sex reassignment surgery often have trouble in many of the following areas; fitting in with peers; making friends; confusion; depression; and shame. One example of a failed sex reassignment case is one of Dr. Money's patients; a Canadian boy named Bruce. The family had twin boys who they decided to have circumcised at 8 months. One of the boy's circumcisions was botched so badly that his penis was destroyed. Dr. Money advised the parents to have the boy surgically reassigned as a girl and raise him as a girl. The parents followed Dr. Money's advice and renamed their son. For a decade this story appeared in medical journals and books as a success story known as the John/Joan case stating that Joan behaved like any active little girl. This was far from the truth. Dr. Diamond's interview with the parents and twin brother revealed that despite the parents attempts to treat Joan like a girl the she had never acted like a girl, instead she had behaved much more like a boy and had talked of wanting to be a boy.

In kindergarten, she was faring so poorly in adapting to her feminine role that her teachers wanted to leave her back. This continued grade after grade as well accompanied by relentless ridicule from her peers, one girl even asked" why does Joan insist on standing up when she goes to the bathroom?"(Colapinto) As early as age 7 she talked of wanting a mustache, toy cars, guns, and to be in the Cub Scouts. As a result, she never made friends and never really fit in. At age 12, Joan was put on estrogen to help her develop as a girl and further problems began to arise. At one point, Joan told the endocrinologist she had thought she was a boy since the second grade. Joan began refusing the estrogen treatments and binge eating to hide the breasts she was developing. She refused the surgery to give her a vagina and, at 14 refused to ever return to Johns Hopkins stating that she would kill herself if she ever had to go back. Joan then changed her name to John and assumed the identity of a boy. Her parents, under the advice of a psychologist, finally confessed to John that she had started life as a boy. They began testosterone injections followed by surgery to create a penis, under his insistence, when he was 16. Further psychological problems followed, but John is now living as a man and happily married.

John was not the only one having psychological problems dealing with the sex assignment. His mother fell into repeated clinical depression requiring hospitalization. His father became an alcoholic. His brother resented all the attention paid to his sister and began rebelling, dropped out of school, and attempted suicide by drinking drain cleaner. Both children can recount games, as early as age 6; Dr. Money had them play, during their annual visits, out of a belief that "sexual rehearsal" helps to solidify the new sexual identity. Dr. Money had Joan get down on all fours and had her brother come up behind her and grind his pelvis into her buttocks; or Joan would be made to lie down on her back, legs spread, as her brother was made to lie on top of her. Their parents were unaware of these "sexual rehearsals" that were going on. This case has led researchers to reconsider Dr. Money's theory that gender identity begins after birth. (Kipnis)

Many children, that have undergone sex reassignment at birth, are not having their condition explained to them. In effect they are being lied to; and by puberty they know that something isn't right. Max Beck, another intersexed child reassigned at birth, was carted to New York every year for medical treatments. As he reached puberty, it was told to him that he was a woman that had not finished growing. After each treatment Max recalls no one ever uttering a word about it until the next annual treatment trip. Regarding the annual trips, Max stated "I knew this didn't happen to my friends." (Fraker) This lack of explanation by the parents results in the inability to make sense of their experiences. Parental and physician emphasis on the benefit of the medical procedures without explanation results in emotional disassociation that does not allow understanding of the medical treatments. Dishonesty on the part of the physician and/or parents makes the child feel hurt, while being told that he or she is being helped.

When Angela Moreno was at age 12, her parents informed her she was having her ovaries removed for health reasons. Angela's parents knew of her actual condition, a condition in which an XY (female) fetus fails to respond to androgens during the pregnancy and is born with externally normal appearing female genitalia but male undescended testicles. At puberty, her undescended testicles began to produce testosterone, resulting in the enlargement of her clitoris. Now at age 25 Angela states "It was never addressed to me that they were going to amputate my clitoris. I woke up in a haze of Demerol and felt the gauze, the dried blood. I just couldn't believe they would do this to me without telling me." (Batz)

Medical treatment, including surgery often has the same effect as child sexual abuse. Like victims of sexual abuse, intersexed children are subjected to repeated genital traumas that are kept secret both within the family and in the culture surrounding it. They are frightened, ashamed, misinformed, and injured both physically and mentally. Many of these children experience their treatment as a form of sexual abuse, and view their parents as having betrayed them by letting the medical professionals violate them. As with sexual abuse, the psychological effects are tremendously damaging to the child as well as the adult later in life. Physicians recommend counseling for their intersexed patients. However, as Ann Fausto-Sterling, counselor at Intersex Society of North America, notes "in truth our medical system is not set up to deliver counseling in any consistent, long-term fashion". (Fausto-Sterling) The intersexed child, as a result, is often left to deal with the psychological problems themselves.

Dr. William Reiner, a child psychologist at Johns Hopkins University, feels that the most important sex organ is the brain. Hormones, in addition to dictating physical development, also organize the brain to bias an individual for future male-typical or female-typical behaviors, for example, laboratory experiments on mammals have elicited male behavior patterns in adult XX females after in utero exposure to androgens at critical stages of fetal development. Likewise, female behavior patterns have been promoted in XY male mammals by prenatal exposure to anti-androgens. These same phenomena have been observed in humans. This type of research supports the view that prenatal endocrinology biases psychosexual development by affecting the central nervous system. In contrast to earlier theories regarding babies being born sexually neutral, the hormones released during fetal brain developed account for instinctive behavior patterns regardless of sex reassignment surgery. While it remains to be seen how deeply our gender behavior is neurologically attached to fetal development. Variations occur however, independently at many different stages of development. As a result, the total number of biological and or psychosocial possibilities is very large. The study of intersexuality forces us far from the view that humanity comes in two mutually exclusive sexes, readily distinguishable at birth by the presence or absence of prominent external genitalia.

Dr. Reiner is now doing follow-up research on intersexed individuals who have and have not been sexually reassigned. Dr. Reiner contends that some surgeries are medically necessary and many seem to turn out just fine, but he hopes to sort out some of the mysteries. Dr. Reiner is currently following the lives of 700 children born with ambiguous genitals, 40 of whom had their sex reassigned at birth. He feels that boys will be boys and girls will be girls and they know better than the doctors or parents who they are. Dr. Reiner is working in cooperation with the Intersex Society of North America. The Intersex Society of North America is a group of more than 1400 people who don't fit the typical definition of male or female. Cheryl Chase, founder of the Intersex Society on North America, started out life as Charlie. She was born with both ovarian and testicular tissue. Doctors later decided she was potentially fertile and had a short penis so she was better off a girl. They said that if she developed as a male she would not be able to father a child. At 18 months Charlie was surgically reassigned female and renamed Cheryl. She was in her 20s and living as a lesbian when she found out the truth about her birth. Like many others who have undergone sex reassignment surgery, Cheryl reports that missing parts and scarring often make sex more likely to bring pain than pleasure. Like many experts, Cheryl does not oppose the non-surgical assignment of sex at birth.

Instead Cheryl believes that the surgical assignment of sex should be made only out of medical necessity and with full parental knowledge and understanding. For years Cheryl has fought to delay surgery until the intersexual child is old enough to display which traits are normal for him/her. Cheryl believes that intersexed children should have the right to make the decision regarding surgical alteration. Likewise, many researchers now oppose surgical assignment being done prior to the child being able to give informed consent. (Lehrman) Dr. Reiner and other researchers at Johns Hopkins University stated to the press on Friday, May 12, 2000 that they now question the practice of surgical reassignment at birth.

A group of researchers at Johns Hopkins University have tracked the development of 27 children born without a penis. The infants were otherwise male with normal testicles, male genes, and male hormones. 25 of the children were sex reassigned at birth and raised as girls. All of the children, now ages 5 to 16, exhibited the rough-and-tumble play of boys. 14 of the children declared themselves to be boys, in one case as early as age 5. The two children who were not reassigned fit in well with their normal male peers and are better adjusted psychologically than the reassigned children. This study supports Dr. Reiner's theory that children may well know who they are far better than doctors do. (Hettena) While no annual tally of infant sex reassignments has ever been made, researchers make a conservative estimate that three to five cases crop up in every major United States city each year. Globally, the figure is at 1,000 per year. In the 25 years since Dr. Money’s first published procedure, as many as 20,000 to 30,000 similar sex reassignments may have been performed.

Situations regarding sex reassignment at birth are now appearing in the court system. An unusual question in the court system is, can a physician change the gender of a person with a scalpel, drugs and counseling, or is a person's gender immutably fixed at birth? The answer to that question has definite legal implications that present themselves in a case involving Christie Lee Littleton. Christie was born in San Antonio in 1952, a physically healthy male, named Lee Cavazos Jr. At birth, Christie had normal male genitalia: penis, scrotum and testicles, but problems with her sexual identity developed early. Christie states that she considered herself female from the time she was three or four years old, despite physical development. Her distressed parents took her to a physician, who prescribed male hormones. These were taken, but were ineffective. At 23, she enrolled in a program at the University of Texas Health Science Center (UTHSC) that would lead to a sex reassignment operation. On August 31, 1977, Christie's name was legally changed to Christie Lee Cavazos. Under doctor's orders, Christie also began receiving counseling and female hormones. Between November of 1979 and February of 1980, Christie underwent three surgical procedures, which culminated in a complete sex reassignment. Christie's penis, scrotum and testicles were surgically removed, and a vagina and labia were constructed. Christie additionally underwent breast construction surgery. The program at UTHSC follows the guidelines established by the Johns Hopkins Group. Based on these guidelines, Christie was diagnosed psychologically and psychiatrically as a genuine male to female transsexual. Two attending physicians testified that true male to female transsexuals are, in their opinion, psychologically and psychiatrically female before and after the sex reassignment surgery. Christie married Jonathon Mark Littleton in Kentucky in 1989, and lived with him until his death in 1996. Christie filed a medical malpractice suit under the Texas Wrongful Death and Survival Statute in her capacity as Jonathon's surviving spouse. The sued doctor filed a motion for summary judgment. The motion challenged her status as a proper wrongful death beneficiary, asserting that Christie is a man and cannot be the surviving spouse of another man. The state defender cited Texas statute Tex. Fam. Code Ann. § 2.001(b) (Hardberger), which, like most other states, does not permit marriages between persons of the same sex. Sadly, the presiding judge agreed with the jury, that Texas would not recognize the marriage. The judge dismissed her case.

Court cases like Christie's put the intersexual community in an awkward predicament. Sex reassignment surgery being done on infants can prohibit them from ever legally marrying and raising a family. This directly conflicts with the purpose of the surgery, to normalize the individual. None of the Laws on the books, Federal or State addresses the issues of intersexed individuals. The laws in place now treat them as homosexuals rather than the intersexuals they are. Congress has passed the Defense of Marriage Act (DOMA), which defines marriage for federal purposes as a "legal union between one man and one woman". It also provides that no state "shall be required to give effect to any public act, record, or judicial proceeding of any other state respecting a relationship between persons of the same sex that is treated as a marriage under the laws of such other State...or a right or claim arising from such relationship." Defense of Marriage Act, Pub. L. No. 104-109, § 2(a), 110 Stat.2419 (1996) (codified as amended at 28 U.S.C.A.§ 1738C (Hardberger).

The Intersex Society of Northern America has come up with a recommended method of treatment which many physicians and child psychologists are now agreeing with. The method of treatment starts with refraining from surgery unless it is medically necessary to correct a life threatening condition. The family is then recommended to seek immediate counseling to include thorough exploration of all medical and surgical options. The family's counseling should also incorporate how to deal with gay or lesbian tendencies in their child as the child matures. A great number of intersexuals develop into gay, lesbian, or bisexual adults or choose to change sex. The child should start counseling as soon as they are old enough to be informed of their medical condition. The option of surgical or hormonal intervention should be offered around puberty. Intervention should be undertaken only at the request and with the informed consent of the intersexual child. The child should also be afforded the opportunity to discuss sexual function with others who have undergone similar surgeries. The child is the one making the trade off, as whatever form of intervention elected will carry with it side affects that can include physical scarring, psychological disturbances, loss of sexual function, loss of fertility and in part the loss of identity. (Intersex)

As a firm rule, doctors should never undertake surgery, unless there are disproportionate hazards associated with all of the other options. Surgery should be avoided unless two types of evidence are at hand. First, one needs to know that comparable patients generally do well after the surgery, such data is not at hand regarding the adult beneficiaries of sex reassignment. Second, one needs to know that comparable patients generally do badly without the surgery. Since surgery is always harmful per se, it should never be done unless there is an expectation of ample compensating benefits. Because this evidence is lacking, the surgical assignment of sex remains an experimental procedure, one in which the results cannot be properly assessed until at least 20 years after the intervention. Accordingly, it is not possible for a patient's parents to give informed consent to these procedures because the medical profession has not systematically assessed what happens to the adults these infant patients become. There are now many thousands of grown intersexuals who have and have not had surgical and hormonal treatment. Retrospective outcome studies can now be done on these adults, to uncover the comparative effects of treatment and non-treatment. Pediatricians have an obligation to assess the final products of their handiwork. These studies may be of significant benefit to intersexuals themselves as well as their families. Sex reassignment surgery on intersexuals should only be done with the informed consent of the patient. This rules out decisions at birth based on the fear of the unknown.

Sources Cited
Batz, Jeanette, Columnist; "The fifth sex"; Riverfront Times Newspaper; 27 November 1996
Bradley, Susan J., Gillian, D. Oliver, Chernick, Avinoam B., and Zucker Kenneth J.; "Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reassignment at 7 Months, and a Psychosexual Follow-up in Young Adulthood."; 1998; Pediatrics (Electronic Pages) 102 (1):E9. Available from http://www.pediatrics.org/cgi/content/full/102/1/e9
Colapinto, John; "The True Story of John/Joan"; Rolling Stone; 11 December 1997; pages 54-73+92-97.
Diamond, Milton Ph.D.; " Pediatric Ethics and the Surgical Assignment of Sex"; Journal of Clinical Ethics;
December 1998; Ver: 16.6.1.
Dreger, Alice; ""Ambiguous Sex" or Ambivalent Medicine?"; The Hastings Center Report ISSN 00930334;
May/June 1998; Volume 28, Issue 3, Pages 24-35.
Fraker, Debbie; "Hermaphrodites come out fighting: New intersex movement challenging need for corrective surgery."; Southern Voice; 19 September 1996; pages 14-16.
Fausto-Sterling, Anne Ph.D.; "The Five Sexes: Why Male and Female are not enough"; The Sciences; 1993-MAR/APR; pages 20-24.
Hardberger, Phil, Chief Justice, San Antonio Court of Appeals; "288th District Court, Bexar County, Texas: Trial Court No. 98-CI-15220"; 27 October 1999.
Hettena, Seth; Virginian Pilot; May 12, 2000.
Hyena, Hank, Columnist; "The Sex-Switching Saga of "Bruce-to-Brenda""; Salon Health & Body; www.salon.com.
Intersex Society of North America (ISNA); "Recommendations for treatment: intersex infants and children" Intersex Society of North America, P.O. Box 31791, San Francisco, CA 94131; www.isna.org.
Kipnis, K. Ph.D. and Williamson, G. Ph.D.; "Nontreatment decisions for severely compromised newborns," Ethics 95 (1984) pages 90-111
Lehrman, Sally, Columnist; "Sex Police", Salon Healthy & Body; www.salon.com.

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