Most parents and physicians opt for surgery the two

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Unformatted text preview: y as adult females. Therefore, all kids who are 46,XX with congenital adrenal hyperplasia or who are 46,XY with complete androgen insensitivity syndrome should be assigned as females, and so on. Furthermore, according to this study, sex assignment should happen as quickly as possible after a full evaluation by the medical team. Notice that to this point nothing has been said about surgery. And some, perhaps many, believe that nothing needs to be said at this point. According to a 2004 report, “All [involved] should understand that a decision to raise an infant as a boy or girl in no way depends on surgery, per se.”7 And the 2007 consensus similarly concludes that, even after assignment of a sex, “appearance-altering surgery is not urgent.” This seems, at least in part, to be a concession to the efforts of a large number of people, including intersex people like Cheryl Chase (born Brian Sullivan) who have campaigned for years to educate people about the realities of intersex persons and surgery.8 Still, the next consideration according to the 2007 consensus guidelines is surgery: “Rationale for early reconstruction includes ben- 120 Between XX and XY eficial effects of estrogen on infant tissues, avoiding complications from anatomic anomalies, satisfactory outcomes, minimizing family concern and distress, and mitigating the risks of stigmatization and gender-identity confusion of atypical genital appearance. Adverse outcomes have led to recommendations to delay unnecessary genital surgery to an age of patient informed consent, although the relative risks and benefits are unknown. . . . The goals of genital surgery are to maximize anatomy to enhance sexual function and romantic partnering.”9 Another source refers specifically to feminizing surgery: “The immediate goal is to provide the external genitalia with an esthetic and feminine appearance. The long-term goals are to produce a functional vagina of sufficient size for sexual intercourse, to retain sexually sensitive tissue to allow orgasm, and if internal genitalia permit, to preserve fertility potential.”10 Choosing to raise an intersex child as either a boy or a girl is important, but for some it is not enough. Legitimate fears of stigmatization and social isolation, coupled with the greater likelihood of success of some surgeries during infancy, drive many families and doctors to seek early surgical solutions to sexual ambiguity. Add to that the mythology that surrounds so much about sex in our society, and it becomes easy to understand why the solutions to sexual ambiguity still frequently include surgery. At that point the question becomes not if, but how? The problem now is how to choose among literally dozens of surgical approaches. Feminizing Surgeries The single most common cause of genital ambiguity is congenital adrenal hyperplasia (see page xx). When enlarged adrenal glands begin to pulse the developing fetus with testosterone, 46,XX females start to look, to varying degrees, like males. The most common consequences include an enlarged clitoris and a less than fully developed vagina. Most parents and physicians opt for surgery. The two procedures most commonly performed to eliminate these “abnormalities” through genitoplasty (reconstruction of the genitalia) What We Do About the Ambiguous Child 121 are clitoroplasty—clitoral reduction/resection, and vaginoplasty—construction or enlargement of a vagina. Clitoroplasty seems to be the simpler and the more uniform of the two procedures. First the surgeon cuts and peels away the skin surrounding the shaft of the phallus, leaving only a small strip of skin connecting the skin on the head and at the base of the phallus. He or she then removes a pie-shaped section from the head of the phallus and sutures the remainder back together to form a smaller, more clitorislike structure with hopefully at least some of the sensitivity of the glans intact. Then, to shorten the shaft, the surgeon cuts out a portion of the middle of the shaft of the phallus, discards it, and sutures the remaining pieces back together. The completed structure can then be slipped into what is or will become the child’s vulva—if need be, constructed from the remains of the skin peeled away from the penis and a portion of the scrotum.11 Vaginoplasty is an entirely different matter. A partial listing of techniques for vaginoplasty includes: the posterior omega-flap method, total urogenital sinus mobilization method, the posterior sagittal approach, the posterior sagittal pararectal approach, vaginal tract without skin graft, the split-thickness skin graft vaginoplasty, skin-flap vaginoplasties, bowel-segment vaginoplasties, amnion vaginoplasties (in which a section of human amnion from the amniotic sac is used to create a vagina), peritoneum vaginoplasties (in which a portion of the lining of the peritoneal cavity is removed and rolled up to create a vagina), bladder mucosa vaginoplasties (in which the bladder is filled with saline, the muscle opened to the level of the mucosa, and the mucos...
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This document was uploaded on 02/04/2014.

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