Talk:Intersex surgery
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1. abnormal is an objective term that is used to describe any deviation from usual; substituting several words that together are less clear is not an improvement of either style or truth.
2. Your substitution suggests a politically motivated denial of simple fact in order to push a specific opinion on a recently advocated but unproven management approach. I have tried to do justice to the controversy, but have tried to present your view as one of several different perspectives since at present we have neither social consensus nor long-term outcome evidence of superiority. Would you describe cosmetic surgery to remove a blood vessel malformation of the skin a procedure to "make the skin more socially acceptable"? You might in some contexts, but not in the intro to an encyclopedia article.
3. I added a sentence in the controversies section to represent what I suspect is your viewpoint: Within the last decade, some people have raised the question of whether surgery to correct abnormal genitalia should be done at all. Opponents of all "corrective surgery" on abnormal genitalia suggest we should be attempting to change social opinion regarding the desirability of having genitalia that look more average, rather than performing surgery to try to make them more like other peoples'. Is this a fair representation? Alteripse 00:45, 13 Nov 2004 (UTC)
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[edit] recent changes
A couple of user:cherylchase's recent changes are excellent (especially the point that perhaps doctors and parents consider a gender identity change the worst outcome). However, a couple are not. The listing of goals is not the place to make unsubstantiatable accusations of "unclear thinking". You may disagree with the goals as is, and should be, clearly explained in the article, but the surgeons who do the surgery and the parents and patients who consent to it can usually formulate exactly what outcomes they are wishing for. There is rarely anything unclear about the intentions of surgery. I have attempted to make it very clear that some of the purposes are controversial this can even be emphasized further as one perspective on this issue, though not as the only perspective on this issue. Much less controversial is the fact that not all the goals (e.g., sexual function) are achieved in a large proportion of cases. This is explicitly stated, and elaborated even further in the article on history of intersex surgery. May I suggest going a piece at a time about the things you would like to change, and explaining on talk page? That is the usual custom here for articles with content that may be controversial. Thanks. alteripse 22:45, 3 May 2006 (UTC)
[edit] "abnormal"
"abnormal" is a term that describes larger than usual penises, and smaller than usual clitorises. But these deviations from usual do not create a wish for surgery on the part of parents or doctors. There's a useful clue in that lack of symmetry about what is prompting surgery. Cherylchase 17:00, 5 May 2006 (UTC)
Pediatric endocrinologists spend time every day sorting out "atypical" or "abnormal" patterns of physical development from disease (tall, short, early, late, heavy, thin, big body parts, small body parts, too much hair, too little hair, etc). They are quite familiar with the concept of "abnormal but healthy and not in need of intervention." They are also familiar with people who are "happy that there is no disease but can you make it more normal anyway?" However, I am not following your clue. alteripse 22:29, 5 May 2006 (UTC)
The clue is that what motivates the surgery is not simply a wish to correct an abnormality, but rather a wish to correct blurring of sex. A clitoris that is smaller than average, or even absent, goes unremarked, but a clitoris that is larger than average is a candidate for surgery. Likewise, larger than average penises are not candidates for surgery (or even for distress), but smaller than average penises are.
The language that doctors use to describe larger than average clitorises and smaller than average penises is emotionally charged, and asymmentric. Borrowing from (Kessler 1998):
The excision of a hypertrophied clitoris is to be preferred over allowing a disfiguring and embarrassing phallic structure to remain. (Gross 1966)
[P]atients with obtrusive clitoromegaly have been encountered . . . [N]ine females had persistent phallic enlargement that was embarrassing or offensive and incompatible with satisfactory feminine presentation or adjustment. (Randolph 1981)
Female babies born with an ungainly masculine enlargement of the clitoris evoke grave concern in their parents . . . [The new clitoroplasty technique] allow[s] erection without cosmetic offense. (Newman 1992)
Failure to [reduce the glans and shaft] will leave a button of unsightly tissue. (Kogan, S 1983)
[Another surgeon] has suggested . . . total elimination of the offending shaft of the clitoris. (Randolph 1970)
[A particular surgical technique] can be included as part of the procedure when the size of the glans is challenging to a feminine cosmetic result. (Allen 1982)
The language used to describe small penises has a very different emotional valence:
a boy with this insignificant organ . . . doomed to life without a penis. (Newman 1992)
the most heartbreaking maladjustment attends those patients who have been raised as males in teh vain hope that the penis will grow (Newman 1992)
Large clitorises are ugly, offensive. Small penises are pitiful.
Kessler, S. (1998). Lessons from the Intersexed. New Brunswick, New Jersey, Rutgers University Press.
Gross, R. E., J. Randolph, et al. (1966). "Clitorectomy for Sexual Abnormalities: Indications and Technique." Surgery 59(2): 300-8.
Randolph, J., W. Hung, et al. (1981). "Clitoroplasty for Females Born with Ambiguous Genitalia: A Long-Term Study of 37 Patients." Journal of Pediatric Surgery 1(6): 882-887.
Newman, K., J. Randolph, et al. (1992). "The Surgical Management of Infants and Children with Ambiguous Genitalia: Lessons Learned from 25 Years." Annals of Surgery 215(6): 644-653.
Kogan, S., P. Smey, et al. (1983). "Subtunical Total Reduction Clitoroplasty: A Safe Modification of Existing Techniques." Journal of Urology 130(October): 746-748.
Randolph, J. and W. Hung (1970). "Reduction clitoroplasty in females with hypertrophied clitoris." Journal of Pediatric Surgery 5: 224-230.
Allen, L., B. Hardy, et al. (1982). "Surgical management of the enlarged clitoris." Journal of Urology 128: 353.
Cherylchase 05:44, 6 May 2006 (UTC)
I am truly shocked at this. The motives you impute for surgery are ridiculous and the worst kind of dishonest ideological cant. The difference between trying to correct a small penis or a large clitoris but not a large penis or a small clitoris is very simple: no one is asking doctors to correct a large penis, not because doctors are the "enforcement agents for a heterosexist hegemony" (to use one of the more absurd caricatures). Re-read my paragraph: it is really the way we think about physical anomalies. If the patient or parent doesn't consider a large or small phallus a problem, we usually don't either. You can find just as "emotive" language in medical texts describing cleft lips. And of course it is "asymmetric": check out the numerous websites devoted to distress about gynecomastia, hirsutism, and penis size. There are no websites emotively describing the anguish of a boy with no breast development or a girl with no lip hair. You want to blame the doctors because most males want to be more "male" and most "females" want to be more female, or their parents want that for them?
In terms of trying to avoid "blurring" of physical sexual characteristics, our patients seek help to do so far more often than we suggest it. What do you think is the reason we see so many adolescent girls distressed over their lip or arm hair or small breasts, or boys distressed over pubertal gynecomastia? We have 100 conversations with patients or families about how some unwanted "cross-sex" characteristic is normal for every 1 conversation where we try to persuade someone that a feature is too feminine or too masculine to go untreated. And guess what: if people still want help changing it, we tell them about hair removal specialists or surgeons.
The many doctors who support ISNA are willing to ignore this type of insulting silliness. If you want to know how ISNA can improve communication with the others, ask them why they do something instead of making up stupid motives. alteripse 16:40, 6 May 2006 (UTC)
[edit] rationales for appearance-altering surgery
"Opponents of all 'corrective surgery' on abnormal genitalia suggest we should be attempting to change social opinion regarding the desirability of having genitalia that look more average, rather than performing surgery to try to make them more like other peoples" is not quite right. I think that coming to some agreement first on what are the rationales for surgery will let us make more progress on an accurate characterization of the views of opponents of all appearance-altering surgeries.
I'm going to discuss here the earliest articulated rationale for surgery. The rationales have shifted over the years; we can discuss later rationales after this one.
The famous 1955 papers by Money, Hampson, and Hampson say that there are two reasons why early surgery to normalize the appearance of the genitalia is necessary. First, the child could not develop a gender identity concordant with the sex assigned unless the genitals had an appearance congruent to the sex assigned, and that this should happen before the child is 18 months old. Second, the articles say that gender identity is socially determined, largely through interaction with the parents. Thus, the parents must believe that the child has a "true sex" which the doctors have uncovered and which is congruent with the sex assigned. Unless the genitals have an appearance normal for the sex assigned, the parents will not believe that is the true sex, and they will not be able to interact with the child in such a way as to cause the child to develop a concordant gender identity.
This theory is no longer very popular. It is contradicted by many cases in which children (born with or without intersex anomalies) developed gender identity discordant with the sex assigned, as well as an extensive history of people who developed a socially acceptable gender identity despite growing up with ambiguous genitalia and without surgery. The most famous case of discordant gender id is recounted in (Colapinto 2000). The phenomenon of transsexuality is also relevant; these individuals develop discordant gender identity despite completely normal genital appearance. A summary of information about individuals who have done well despite growing up with ambiguous genitalia and no surgery is available at ISNA's FAQ.
Surprisingly, Money himself is the author of some of this information. His first encounter with an intersexed person is described on page 4 of the Prologue to his collection "Venuses Penuses" (sic).
At Harvard, I probably would have gone down the mainstream of clinical psychology of the time except for the coincidence of a case presentation in the Fall of 1949 by George Gardner MD for Social Relations Course 281A, Clincal Problems of Child Guidance, at the Judge Baker Guidance Center in Boston. The case was one of hermaphroditism in a child who had grown up always as a boy despite having been born with, instead of a penis, an organ the size and form of a clitoris. At puberty, he feminized in physique. It is now known in retrospect that his case was one of the androgen-insensitivity syndrome. Psychologically he was a boy and could not entertain the idea of reassignment as a girl. Even though not too much could be achieved by way of surgery and hormone treatment, he was permitted to continue living as a boy. He has since married and become a father by adoption, and has achieved professional recognition in the world of medicine.
Money's 1952 PhD dissertation contains discussion of numerous published cases for the period:
The findings are somewhat disconcerting, for one would not have been surprised had the paradox of hermaphroditism been a fertile source of psychosis and neurosis.. The evidence, however, shows that the incidence of the so-called functional psychoses in the most ambisexual of the hermaphrodites—those who could not help but be aware that they are sexually equivocal—was extraordinarily low.
There are also vingettes of people in (Young 1937) who seemed to be doing quite well without surgery, and who refused Young's offer of surgery.
Money, J., J. G. Hampson, et al. (1955). "Hermaphroditism: Recommendations Concerning Assignment of Sex, Change of Sex, and Psychologic Management." Bulletin of Johns Hopkins Hospital 97(4): 284-300.
Money, J., J. G. Hampson, et al. (1955). "An Examination of Some Basic Sexual Concepts: The Evidence of Human Hermaphroditism." Bulletin of the Johns Hopkins Hospital 97(4): 301-319.
Money, J., J. G. Hampson, et al. (1955). "Sexual incongruities and psychopathology: The evidence of human hermaphroditism." Bulletin of the Johns Hopkins Hospital 97(4): 43-57.
Colapinto, J. (2000). As Nature Made Him : The Boy Who Was Raised As a Girl. New York, Harper Collins.
Dreger, A. D. (1998). Hermaphrodites and the Medical Invention of Sex. Cambridge, Harvard University Press.
http://www.isna.org/faq/healthy
Money, John. 1952. Hermaphroditism: An Inquiry into the Nature of a Human Paradox. Doctoral Dissertation, Harvard University, Cambridge (444 pages). Can be ordered directly from Harvard University’s Widener Library for about $100.
Young, H. H. (1937). Genital Abnormalities, Hermaphroditism, and Related Adrenal Diseases. Baltimore, Williams and Wilkins.
Cherylchase 17:00, 5 May 2006 (UTC)
No quarrel with the history, and many of your papers are already cited in the history article. I'll add a couple more. One of Money's original arguments for operating to normalize genital appearance was to facilitate the ability of the parents to implant a firm gender identity by having no doubt themselves. I heard Money make this argument in the late 1970s, and we can make this more explicit in the history article, but I have not heard this specific argument made as a justification for infant surgery since then. No one would disagree that a genital appearance concordant with a gender assignment does not guarantee a gender identity concordant with gender assignment. But the problem with arguing by exceptions is that it only negates claims that "X always implies Y", and no doctors or psychologists argue that "normal genital appearance always produces normal psychosexual development". Medical management decisions are usually based on probabilities and perceived best choices rather than absolutes, and exceptions must be so numerous as to not seem unusual to negate the argument of surgical proponents that gender identity is more likely to agree with assignment if appearance and assignment are concordant-- and in fact this is a tough proposition to disprove.
Please note I am not trying to present a weak argument against surgery and certainly not to misrepresent reasons for opposition, but much arguing against surgery does exactly that-- misrepresents arguments in favor of it and argues against caricatured, obsolete, or inaccurate rationales. Help me describe the arguments for and against infant surgery as strongly and fairly as possible without misrepresenting either set of arguments. When I have argued against surgery with surgeons or other endocrinologists I have never done so by accusing them of wanting to operate because of "confused thinking" about goals, or because one of the original arguments for surgery was based on an out-of-fashion psychological theory. Arguing that uncorrected, abnormal genitalia does not preclude satisfactory sexual development may be true, but you could also argue against repairing a cleft lip because some people with unrepaired cleft lips manage to achieve satisfactory social development. Some much stronger arguments (if true) against repairing cleft lips in infancy would be that (1) a high proportion of people with repaired clefts cannot eat properly as adults and still need tube feeding, (2) a high proportion of adults with repaired clefts say they wish that they had not been repaired, (3) the complication rate for adult repair is much lower than when done in infancy, (4) the social outcome by objective criteria (likelihood of educational attainment, job achievement, marriage, life satisfaction measures) is worse for people with repaired clefts than unrepaired. Data to support assertions like those would be far more powerful arguments against cleft lip surgery than reminding people that when first performed in the 1940s some people thought "making it possible to smile normally" was essential to healthy social development and now we know there are exceptions. Do you see what a big gap there is between arguing against surgery based on outcome and arguing against it based on an out-of-fashion psychological rationale for it that no one under 50 even remembers? Many doctors think psychological theories come in and out of academic and political fashion more than than they are "proved or disproved", so they don't put much weight on arguments based on their validity anyway.
If you feel that the current description of the principal reason for opposing infant surgery to normalize appearance is misrepresented, how would you better state that concisely and accurately?
- Opponents of surgery for the purpose of normalizing appearance argue that surgery carries risks of harm and complications, and an abnormal genital appearance is less an impediment to healthy psychosexual development than has been thought by many psychologists and doctors.
- Opponents of surgery for the purpose of normalizing appearance to alleviate parental distress argue that instead of incurring the risks of surgery we should be trying to change parental and social values so that abnormal genitalia are not a source of distress.
- Opponents of surgery for the purpose of normalizing appearance to improve psychosexual maturation and adult function say that those who advocate surgery overvalue the role of a "closer-to-normal" appearance in satisfactory psychosexual development.
Are any of the above more accurate? alteripse 22:36, 5 May 2006 (UTC)
[edit] Money theory remained dominant until less than a decade ago
I don't think that Money's theory is "an out-of-fashion psychological rationale for it that no one under 50 even remembers". In (Kessler 1998), Suzanne Kessler reports on assumptions and attributions of meaning revealed in interviews she carried out with six doctors who worked with intersex children in New York. These were three men, three women, one clinical geneticist, two peds endos, one endo, one psychoendocrinologist (guess we know who that is), and one urologist. The represent four different medical centers, no two of them collaborate on research or work together on a team. They all had extensive clinical experience with various intersex syndromes, and some are internationally known researchers in the field of intersexuality. They were selected based on their prominence in the field, and in such a way as to cover four different centers. All were interviewed in the spring of 1985, in their offices.
All six specialists told Kessler that management of intersexed chases is based upon the theory of gender proposed by Money in 1955 and elaborated in 1972. From the transcribed interviews:
I think we [physicians] have been raised in the Money theory. (an endocrinologist)
We always approach the problem in a similar way and it's been dictated, to a large extent, by the work of John Money and Anke Erhardt because they are the only people who have published, at least in medical literature, any data, any guidelines. . . . And I don't know how effective it is. (another endo)
Kessler on the pervasiveness of the Money theory:
Contradictory data were not mentioned by any of the six physicians, and have not reduced these physicians' belief in the theory's validity. Although only one of the physicians interviewed has published with Money, they all essentially concur with his views and give the impression of a consensus that is rarely encountered in science. The one physician who raised some questions about Money's philosophy and the gender theory on which it is based has extensive experience with intersexuality in a nonindustrialized culture where the infant is managed differently with no apparent harm to gender development. Even though psychologists fiercely argue issues of gender identity and gender role development, doctors who treat intersexed infants seem untouched by these debates. There are still, in the late 1990s, few renegade voices within the medical establishment. Why Money has been so single handedly influential in promoting his ideas about gender is a question worthy of a separate substantial analysis.
I don't believe that the Money rationale for early genital surgery fell out of favor until after the David Reimer story hit Rolling Stone in 1997. The story was known earlier (Diamond was presenting it in Fall 1995, and ISNA published an account of Diamond's presentation).
I'm not ignoring your question about how best to represent the argument of opponents of surgery. First I would like to demonstrate that rationales for surgery have been guesses, not evidence-based, and that as each rationale has fallen out of fashion, a different rationale has taken its place, and not through a process involving scientific thinking.
Cherylchase 06:15, 6 May 2006 (UTC)
There is no question that John Money was more influential than anyone else in shaping intersex management since the late 1950s, even today. I was referring to your specific assertion that the original rationale for surgery to normalize appearance is the premise that the appearance must be normal in order for parents to "teach" or "implant" a firm gender identity in a child. I agree 95% with your last sentence--- my 5% reservation is that "evidence-based" is a graded quality rather than a binary one, and even Money based his theories and recommendations on observed case evidence described in the very papers you cite. You can claim his evidence was weak or that it was misinterpreted, but it was remarkably similar in quality to the strongest evidence that ISNA used to challenge the dominant approach a decade ago, which was basically, "look at all these unhappy people treated the old way; there must be a better approach." Right? alteripse 16:03, 6 May 2006 (UTC)
Actually, I don't see where Money said "look at all these unhappy people treated the old way." In fact, he published a large volume of material that showed people were doing quite well the old way. I think that a mystery remaining for historians to address is why Money, between 1952 and 1955, changed his mind, and began to write that intersexuality was simply incompatible with a life worth living. Just to be clear, I'm not interested in villainizing Money. I don't think that he is responsible for the history of intersex surgeries and secrecy. Rather, he provided a plausible rationale for something that people were already motivated to do. Without Money, there might have been different decisions made about sex assignment, and different stories told to parents and patients, but I doubt that there would have been less surgery and secrecy.
The contemporary argument against surgery is not as weak as Money's earlier rationale for surgery. A decision to perform a risky and irreversible intervention requires a higher level of evidence than the decision to practice conservative medicine. There's no demonstrated benefit of infant surgery. Outcome studies, though small and open to criticism about sample bias, and viewed with skepticism by leading surgeons ("wouldn't have happened if *I* had performed the surgery," or "my new technique is so much better than those older techniques") support the types of harm pointed out by intersex adults subjected to early surgeries. Cherylchase 16:30, 6 May 2006 (UTC)
There is no mystery about why he concluded gender identity is "taught" after a few years at Hopkins: they were seeing a parade of patients with the same chromosomes and diseases but some had been assigned one sex and some the other. They saw clearly that sex of assignment and rearing was a far stronger predictor of gender identity than sex of chromosomes, gonads, or hormones (at least for people with intersex conditions). That fundamental observation is still clearly true, and still underlies much of our thinking about human sexual development. It was hubristic to think that sex of rearing starting in the second year of life could offset completely concordant gonads, chromosomes, hormones, and original assignment.
And yes, the controversy over infant surgery is over weighing risks and benefits and outcomes, not imputed motives. As with other surgery for cosmetic purposes, not everyone agrees there is "no demonstrated benefit" to making a baby's genitalia look more normal, but it is clearly a "benefit" that is largely subjective and culturally influenced, and the objective risks need to be accurately ascertained and understood by all concerned. alteripse 17:15, 6 May 2006 (UTC)
