For example in a paper by drs jorge daaboul and joel

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Unformatted text preview: tralia, the United States, and Europe—from 3.5 cm in the United States to 3.6 cm in India at birth], 3) apparent male genitalia with bilateral undescended testes, micropenis, isolated hypospadias (when the urethral opening falls somewhere below and behind the tip of the penis), or mild hypospadias with undescended testis, 4) a family history of DSD, or 5) when karyotype and physical appearance disagree.”1 A much earlier study did deal with issues of clitoral size and the limits of normalcy. In this report the author devised what he called the “clitoral index,” a number obtained by multiplying width of the glans by the length of the phallus. According to this study, a clitoral index of less than 3.5 is normal and a clitoral index of greater than 10 is cause for concern. So we do have a set of numbers to refer to for help in estimating the normalcy of either a penis or a clitoris.2 Therefore, careful physical examination, karyotyping, and blood work are all recommended whenever DSD is suspected. There have been a surprisingly large number of papers and study groups offering advice on how to identify and deal with newborn children with sexual ambiguity. In the recent past, at least, most of them Unacceptable! (surgery) It’s a boy! (over 1") Intersex Society of North America It’s a girl! (under 3/8") This Phall-O-Meter created by the Intersex Society of North America shows the current medical standards for children born with ambiguous genitalia. 118 Between XX and XY have reached these same basic conclusions—be thorough and use every piece of information available to help with the decision. This seems reasonable. After all, if a newborn child shows any sort of physical abnormality, any sane person involved would want, as soon as possible, to know what was unusual about this child and what might be done about it. But beyond the approach and the speed of the evaluation, there is much less agreement among physicians. Once, this wasn’t a problem. Before the early 1990s, physicians often chose to keep parents in the dark about their unusual children. This tactic was an offshoot of Dr. John Money’s powerful influence on perceptions of human sexuality. Money believed that the final sex of any child was determined primarily, if not solely, by the child’s upbringing—all, or very nearly all, nurture, not nature.3 The issue for the pediatrician was to determine the optimum sex of rearing, regardless of the genetic sex. Determining the optimum sex could involve any number of things, including, with older children—according to one of Dr. Money’s patients—screening pornographic movies and observing the patient’s response.4 The less they knew about what the physicians were up to, the less likely the parents were to interfere with the doctors’ visions for the children. If nobody but the doctor knew, girls would never suspect that they were boys or vice versa. By the beginning of this century, some physicians (along with most parents and patients) had begun to advocate for a more reasoned approach. For example, in a paper by Drs. Jorge Daaboul and Joel Frader, the two physicians proposed a new terminology and a transfer of more of the physicians’ powers into the hands of parents and, when possible, the affected children. As these two doctors stated, too often “the ‘tradition’ of sex and gender assignment reflects physicians’ preferences, custom, or even bias. The physician-centered approach favors reproductive potential over ease of intercourse or sexual pleasure in the overvirilized female; and ease of intercourse trumps reproductive potential in undervirilized males. . . .” They concluded, “The traditional medical and surgical approach to newborns with intersex maintains a morally and legally unacceptable paternalism.”5 What We Do About the Ambiguous Child 119 The idea that the physician was the best qualified to make life-shaping decisions for families and children foundered but didn’t die. The next step in the evaluation of the potential intersex patient, according to the doctors involved in composing The Consensus Statement on Management of Intersex Disorders, is to assemble the core team (of physicians) and assign a sex. Assigning a sex is complicated, and the final choice depends greatly on the nature of the DSD identified. In general, though, this consensus report suggests that these decisions should be based on studies of the satisfaction of individuals who have had similar experiences.6 In other words, try to find other intersexed individuals who were raised as a boy or girl, for what reasons, under what circumstances, and then figure out who ended up happy and who did not. For example, according to one set of studies, more than 90 percent of 46,XX people with congenital adrenal hyperplasia (which causes the development of nearly male external genitalia) and all patients with complete androgen insensitivity (which causes 46,XY fetuses to develop nearly female external genitalia) who were assigned as females in infancy seem happ...
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This document was uploaded on 02/04/2014.

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