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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
(surgery) It’s a boy!
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
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
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
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This document was uploaded on 02/04/2014.
- Spring '14