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filled by an inflatable mold and inserted into a prepared space), scalp,
buccal mucosa, and fetal-skin vaginoplasties.12
Even a tomish textbook might not offer space enough to discuss all
of these procedures. I’ll describe only a few of the more commonly used
approaches for construction of a vagina in a child with either congenital
adrenal hyperplasia and partial or complete androgen insensitivity syndrome—the two most common disorders of sex development that end
in surgery. In most children with congenital adrenal hyperplasia, there
is at least a rudimentary vagina, though it often does not open directly 122 Between XX and XY after Journal of Urology, 176 (5): 2205–2211 to the outside. In other children there is no vagina at all. Either way, it
is possible to create one.
When there is no vaginal rudiment, a vagina can be fashioned
from a piece of colon (large intestine) or ileum (the terminal section of
the small intestine). A section of bowel offers the advantage that it is
already cylindrical and approximates the structure of a vagina. On top
of that, these tissues secrete mucus, somewhat like a normal, functioning vagina. The surgeon simply cuts out the section of bowel and inserts
it into a hole cut between the clitoris and the anus, sews the section of
bowel in place, and creates a vagina. Usually this turns out to be only
the beginning, and at least one more surgery must follow to construct a
vagina adequate for sexual intercourse.
In baby girls who have severely enlarged clitorises and rudimentary
vaginas, clitoroplasty itself often provides the material necessary for creating a vagina. One commonly used procedure begins with “degloving”
the enlarged phallus—in effect, pulling the skin from the “penis” like
peeling a banana—except for the skin at the tip or glans.
The flaps of phallus skin are then sewn into a tube still attached to
the base of the phallus. The surgeon turns the tube inside out,
pushes it through a hole opened
near the rectum, and stitches the
new vaginal tube to the rudimentary vaginal tube naturally
present. Clitoroplasty is then
performed to reduce the size of
the remainder of the phallus and
to create a more nearly normal
clitoris. Finally, the scrotum or
labioscrotal tissue is manipulated to construct nearly normal-looking labia.13 At the end,
like a canyon carved into human
bedrock, the new clitoris sits, as
Planned incisions for combined clitoroit should, at the apex, just above
plasty and vaginoplasty. What We Do About the Ambiguous Child 123 the vaginal opening, both surrounded by the red-rock folds of the labia
minora and majora. Again, though, the surgeon’s work is likely incomplete, and more engineering and reengineering will have to happen
before such a vagina can achieve its full potential.
Much of the potential pleasure of adult intercourse lies inside that
final bit of phallus still rooted in its native soil. But following most of
these surgeries it isn’t clear if what remains will still provide pleasure. 14
Some people, less changed physically by congenital adrenal hyperplasia, can learn to enlarge their vaginas by self-dilation. These children
begin life with a more nearly normal vagina that opens to the exterior of
their bodies, and they can learn to enlarge their own vaginas by inserting an increasingly larger series of tampon-like tubes that stretch the
tissues and slowly force the vagina to expand—a sometimes painful but
also sometimes effective approach to reshaping the opening.
Many babies with congenital adrenal hyperplasia have additional
issues to contend with. During fetal development, the tissues that will
eventually form the bladder, the urethra, and the vagina begin as a
single unit called the urogenital sinus. Usually, as the fetus rounds out
its development, the vagina, urethra, and bladder separate from one
another and seek out their own geographical spots on the pelvic map.
When that happens, the urethra separates completely from the vagina
and forms a separate tube that connects to the outside, just below the
In many children with congenital adrenal hyperplasia, that separation never happens. The result is a single external opening that divides
internally into two passages, one of which leads to the bladder and the
other to the vagina (or rudimentary vagina).
Traditionally physicians said these children had a “high vagina”
if the vagina joined the urethra before the external sphincter (the
one we become most aware of using after drinking a quart of beer)
and a “low vagina” if it joined the urethra after the external sphincter. The problems with that approach are the same as those inherent
in the two-sex idea. The words don’t really tell us much about the
range of conditions that exist in between and beyond “high” and
“low” vaginas. 124 Between XX and XY Others have tried to eliminate the ambiguities of the high-or-low
model by certain quantifiable measurements.15 But all attempts to
reduce genitalia to...
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- Spring '14