Lundquist Body
Jennifer ELEN 019
Pediatric Ethics and The Surgical Assignment of Sex
One in every 2,000 babies born every year are neither male nor female, they are what is known as hermaphrodites. These children and their families are forced into a life of hardship and encounter many conflicts, which need to be addressed. Should the parents choose the assignment of the sex to a newborn child and subject them to a life of surgery and doctor visits? There are 100 to 200 pediatric surgical reassignments every year. Many of these children are subjected to doctor visits for the rest of their childhood. Worst of all, many of these children find themselves resembling or identifying with the gender opposite of that which their parents chose for them. To protect the lives of these children, it is in their best interest if their parents wait until after they reach puberty before going through with the surgery. Surgery should only be done if the child suffers from further health risks. Over the past five decades, surgical interventions have been recommended as standard procedure for infants who are born with either ambiguous genitalia or who suffer from traumatic genital injury. Surgical advances in this century have made it possible for physicians to choose a gender for the child and then sculpt the appropriate genitalia. Some of the conditions that demand gender reassignment for children can be a result of chromosomal or hormonal defects. Typically males have XY chromosomes, and women have XX chromosomes; however, hermaphrodites are neither male nor female. One reason comes from Turner's Disease where the chromosomes are XO, and there is a sex chromosome missing. Another mutation is the XXY chromosomes, known as Klinefelter's Disease, which occurs in an average of one out of every 1000 births. There is also, Mosaicism, where different cells split into different parts, making up XY and XO chromosomes. Hormonal complications can change the gender of a child during their development through puberty. A male may have XY cells, but not be able to process testosterone. Women can also suffer the same affliction. A 5-alpha-reductase deficiency will turn a female to male at puberty, by giving off too much testosterone. The most common hormonal disorder is known as congenital adrenal hyperplasia, which is a hormonal imbalance that masculinizes XX (female) children.
http://cseserv.engr.scu.edu/studentwebpages/JLundquist/ResearchPaper.htm (1 of 4) [3/10/2002 11:19:38 AM]
Body
These disorders are very traumatizing for children both physically and emotionally. Treatments for these conditions are tedious and expensive. If surgery is decided upon for reconstructive purposes, then pediatric surgeons are a necessity. Also, the patients are forced to have further appointments with pediatricians, endocrinologists, urologists, and more. Concurrently, these children will have to be seen by a psychiatrist, or a psychologist to deal with the emotional stress that these abnormalities bring. Another form of treatment that goes along with surgery is hormonal treatment, which helps with the transformation to either gender. Doctors enhance feminine traits by prescribing estrogen, and testosterone is given to enhance masculine traits. Although medical technology has come a long way, these reassignment surgeries are not always beneficial. One very popular case study is that of identical twin boys born in the 1960's. At the age of 7 months, an electrocautery knife burned one of them during a routine circumcision. The twin who was injured was named John. A psychologist at the Gender Identity Clinic at Johns Hopkins University, named John Money, recommended to the parent's of this injured boy that the child should be surgically reassigned and raised as a girl. It is a fact that it is easier to make a female than to construct a male. By the age of 17 months, John went through with the surgery, and became a female known as Joan. After the surgery, Joan was forced to return to Johns Hopkins for further appointments with doctors, such as visits with several pediatrics, two pediatric surgeons, an endocrinologist, and a team of psychiatrists. By the age of 12, she was put on estrogen for a short while, but later rejected them because she didn't like the way they made her feel. Her family continued to raise Joan as a girl, although she didn't feel quite right. In 1972, Money wrote in, "Man & Woman, Boy & Girl," that Joan had developed into a "normal girl." He concluded that, "sexual identity is a function of social learning through differential responses of multiple individuals in the environment (1)." Money did not believe that gender was hereditary, but learned. However, on the contrary, a Medical Practitioner in 1996 reopened the case of Joan and found that this wasn't the picture at all. The MD said, "in a nutshell, the child was and never became a girl (2)." After interviewing the family, they recollected that John may have looked like a girl, but never acted like one. He rejected girls clothing, toys, and activities. By the age of 7, Joan had rejected the visits to the doctor, feeling that her privacy was violated. It later came out that the parents never told her what was going on, and by the time they did, John felt relieved to know why he "felt" more masculine than feminine. John said that he suspected between the ages of 9 and 11 years that he was a boy and he shared this with his endocrinologist. After this revelation, at the age of 14, John went in for a mastectomy to transform back into a male. By the age of 16 he was attracted to girls, and by 18 he had lost his virginity. When John became 25, he married a woman and adopted his wife's three kids. By the time this was written he was in his thirties and very happy about being a man, a father, and a breadwinner. Following John's original reassignment procedure, his parents felt it best to keep things a secret. The father said that he never even considered telling John until the psychiatrist suggested that it would be in his son's best interest. The mother kept quiet as well to protect her child from the possible and shame emotional damage that could have resulted from the release of such an awkward secret. While their intentions may have been noble, the parents never took into consideration the repercussions of their actions. This in turn led to years of confusion and depression for John, something that his parents were desperately trying to avoid. Medical technologies have made leaps and bounds in the last quarter century. Gender reassignment surgeries were a radically new procedure at this point and no real psychological studies had been done to suggest that such an operation would cause problems for the patient. The belief at the time was that any person recently born into this world was much like a piece of clay, molded and shaped by exterior influences. Doctors felt that reassignment surgery would pose no threat to patients, as they were still too young in life to know the difference in sexes or to even remember the surgeries themselves. The parents, while apprehensive, still held great faith in their doctor and agreed with his decision to perform the surgery. However, the parents were naive to believe that this would fix all of their problems. The technology was fairly new and the parents were unable to know what the outcome would be; however, they should have been skeptical of raising a baby boy as a girl. They were
http://cseserv.engr.scu.edu/studentwebpages/JLundquist/ResearchPaper.htm (2 of 4) [3/10/2002 11:19:38 AM]
Body
worried of the ridicule that John would face as a teenager, but never stopped to consider that they were damaging him emotionally. Fortunately for John, the medical field had advanced enough to return him to his original gender. The doctors should have done further research to identify what constitutes gender, and think of the ramifications before jumping to surgery. John was used as a guinea pig for their research and advancement their careers. Doctors cannot recommend or persuade parents into doing something when they don't even have enough evidence to prove that surgery will be beneficial for the child. These sex reassignment surgeries, besides being expensive for the families, have many other risks. The risks from surgery can be bleeding, infection, or rectovaginal fistula (an abnormal path between the rectum and vagina). If a child already suffers from damaged genitalia, in severe or mild cases, going through with surgery can make the outcome worse than the initial problem. All pediatric surgical assignments should be suspended until these issues are resolved. If a child is injured at birth the best choice is to assign them the sex they were born. It is a little harder to define the gender of a hermaphrodite because they consist of both genders. In this situation the children should be left alone until after puberty to choose the gender, which they believe will best fit them. The intersexed children are the ones who have to live with the decision of the doctors and the parents. They may suffer both physically and emotionally from the severe actions that were taken to protect them. A popular fear of the adults is that the child will be ridiculed in the locker room at school. However, in today's world kids are not forced to shower after physical education, and there is more privacy in the locker room than there was forty years ago. There have been many accounts of transvestites hiding their true identity from the public and coping fine with society. This gives hope for intersexed children. After puberty, a child is more identifiable in both personality and gender. As hormones begin to take over, personality traits such as: likes and dislikes, facial appearance, and body development, it will become easier to conclude what operation should be performed. Being honest with the children and showing them unconditional love will give the children power to make their own destiny. This will also keep the children from having hostility towards their parents or the doctors for making a decision that strongly impacted their future. If reassignment surgery is performed, then the child should be lucky to have turned out as well as John/Joan. He was fortunate to reverse his gender, but he still faced traumatic emotional stress from birth until puberty. Either way, with or without surgery, the child will obtain some emotional stress. However, if the parents are honest and supportive of the child without going through with surgery, then they can ease the pain for the whole family while relieving stress, time, and money. The family will also be much closer without any regrets. The risks of gender reassignment surgery are more harmful than beneficial. Surgery should not be used as a solution to create a perfect child. The child should be appreciated and loved for who they are. If the child is pointed in the right direction, then they will make the right decision, and be mature enough to handle it. Surgery should be only used as a solution if the child's life is already at risk. If not, then gender reassignment surgery should be left as a later alternative in life. Who knows, if the parents are accepting, maybe the child will be happy with itself and find others who believe the same. Surgery may never even be needed. References 1) J. Money and A. Ehrhardt, Man and Woman, Boy and Girl (Baltimore: John Hopkins University Press, 1972) 2) P.K. Donahoe, and J.J. Schnitzer, "Evaluation of the infant who has ambiguous genitalia, and principles of operative management," Seminars in Pediatric Surgery 5 (1996) 3) http://www.ukia.co.uk/diamond/ped_eth.htm 4) http://mind.phil.vt.edu/sex/emma.html
http://cseserv.engr.scu.edu/studentwebpages/JLundquist/ResearchPaper.htm (3 of 4) [3/10/2002 11:19:38 AM]
Body
5) http://www.afn.org/~sfcommend/Ethics.htm 6) http://www.isna.org/library/recommendations.html 7) http://bmei.org/jbem/volume4/num2/scipione.htm
Jennifer, This is a topic that one does not usually hear too much about. I learned something, hopefully others will also. Good presentation of the material, although the ethical analysis could be a bit more systematic. Grade: 95
http://cseserv.engr.scu.edu/studentwebpages/JLundquist/ResearchPaper.htm (4 of 4) [3/10/2002 11:19:38 AM]