Intersex surgery

Intersex surgery is surgery performed to "fix" atypical or ambiguous genitalia, a form of genital reconstructive surgery, primarily for the purposes of making the appearance more normal and to reduce the likelihood of future problems. The history of intersex surgery has been characterized by controversy due to reports that surgery can compromise sexual function and sensation, and create lifelong health issues.[1][2] Timing of surgery (infancy, adolescence or adult age) has been controversial, associated with issues of consent.

Intersex surgery is increasingly recognized as a human rights issue. Intersex organizations, and human rights institutions increasingly question the basis and necessity of surgical intervention.[3][4] In 2011, Christiane Völling won the first successful case brought against a surgeon for non-consensual surgical intervention.[5] In 2015, the Council of Europe recognized, for the first time, a right for intersex persons to not undergo sex assignment treatment[6] and Malta became the first country to prohibit involuntary or coerced modifications to sex characteristics.[7][8][9][10][11]

Purposes of genital reconstructive surgery

The goals of surgery vary with the type of intersex condition but usually include one or more of the following:

Types of surgery

Genital reconstructive surgery can be divided into masculinizing surgical procedures intended to make the genitalia more like those of typical males, and feminizing surgical procedures intended to make the genitalia more like those of typical females.

Masculinizing surgical procedures

Orchiopexy and hypospadias repair are the most common types of genital corrective surgery performed in infant boys, but most of these boys may not be considered to have an intersex condition. Undervirilized boys typically have at least one of these two procedures performed in addition to others described below.

Types of undervirization and malformation for which some type of masculinizing surgery has been performed most often in the last 50 years are:

The disorders above comprised over 90% of reported surgical series from North America and Europe. In a few parts of the world 5-alpha-reductase deficiency or defects of testosterone synthesis, or even rarer forms of intersex account for a significant portion of cases but these are rare in North America and Europe. Masculinizing surgery for completely virilized genetic females with CAH is even rarer.

Orchiopexy for repair of undescended testes (cryptorchidism) is the second most common surgery performed on infant male genitalia (after circumcision). The surgeon moves one or both testes, with blood vessels, from an abdominal or inguinal position to the scrotum. If the inguinal canal is open it must be closed to prevent hernia.

Potential problems: Maintaining the blood supply is the major challenge. If vessels cannot be stretched into the scrotum, or are separated and cannot be reconnected, a testis will die and atrophy.

Hypospadias repair is a relatively simple single procedure if the hypospadias is first or second degree (urethral opening on glans or shaft respectively) and the penis is otherwise normal. Repair of a third degree hypospadias (urethral opening on perineum or in urogenital opening) is more challenging, may be done in stages, and has a significant rate of complications and unsatisfactory outcomes.[12]

Potential problems: For severe hypospadias (3rd degree, on perineum) constructing a urethral tube the length of the phallus is not always successful, leaving an opening (a "fistula") proximal to the intended urethral opening. Sometimes a second operation is successful, but some boys and men have been left with chronic problems with fistulas, scarring and contractures that make urination or erections uncomfortable. It is increasingly recognized that long term outcomes are poor.[13][14]

Urogenital closure closure of any midline opening at the base of the penis. In severe undervirilization a boy may have a "pseudovaginal pouch" or a single urogenital opening in the midline of the perineum.

Potential problems: The most complicated aspect of closure involves moving the urethra to the phallus if it is not already there (i.e., repairing a perineal hypospadias). Fistulas and scarring are the main risks.

Gonadectomy (also referred to as "orchiectomy") removal of the gonads. This is done in three circumstances. (1) If the gonads are dysgenetic testes or streak gonads and at least some of the boy's cells have a Y chromosome, the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing gonadoblastoma. (2) In rare instances when an XX child has completely virilizing congenital adrenal hyperplasia (Prader stage 5), the ovaries can be removed before puberty to stop breast development and/or menstruation. (3) Gonadectomy can be performed in the equally rare instance of a child with true hermaphrodite virilized enough to raise as male, in which ovaries or ovotestes can be removed.

Potential problems: Gonadectomy involves little risk beyond that of any abdominal surgery.

Chordee release is the cutting of ventral penile skin and connective tissue to free and straighten the penis. A mild chordee, manifest as a well-formed penis "bent" downward by subcutaneous connective tissue, may be an isolated birth defect easily repaired by releasing some of the inelastic connective tissue on the ventral side of the shaft. In a complete chordee the phallus is "tethered" downward to the perineum by skin. A more severe chordee is often accompanied by a hypospadias and sometimes by severe undervirilization: a perineal "pseudovaginal pouch" and bifid ("split") scrotum with an undersized penis. This combination, referred to as pseudovaginal perineoscrotal hypospadias, is in the spectrum of ambiguous genitalia due to a number of conditions.

Potential problems: Scarring and contracture are occasional complications, but most unsatisfactory outcomes occur when a severe hypospadias needs to be repaired as well. Long-term complications can include fistulas between colon or upper rectum and skin or other cavities, or between urethra and perineum.

Cloacal repair is among the most complex of the surgeries described here. Bladder exstrophy or more severe cloacal exstrophy is a major birth defect involving inadequate closure and incomplete midline fusion of multiple pelvic and perineal organs as well as the front of the pelvis and lower abdominal wall. The penis and scrotum are often widely bifid (the two embryonic parts unjoined). The penis often cannot be salvaged, although the testes can be retained. Repair may involve closure of the bladder, closure of the anterior abdominal wall, colostomy (temporary or permanent) with reconstruction of the rectum. If the halves of the phallus cannot be joined, they may be removed. The smallest defect in this spectrum is an epispadias. Surgical repair for this is primarily a phalloplasty.[15]

Potential problems: Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term colostomy or vesicostomy. In many cases a functional penis cannot be created. Scarring is often extensive and the lower torso severely disfigured even with fairly good outcomes.

Phalloplasty is a general term for any reconstruction of the penis itself, especially for more unusual types of injuries, deformities, or birth defects. The principal difficulty is that erectile tissue is not easily constructed and this limits the surgeon's ability to make more than minor size changes. Construction of a narrow tube lined with mucosa (a urethra) is a similar challenge.

Potential problems: Minor revisions of the skin are rarely followed by problems. More complicated reconstruction may result in scarring and contracture, which can distort the shape or curvature of the penis, or interfere with erections or make them painful.

Hysterectomy is removal of a uterus. It is rare that a uterus or Müllerian duct derivatives would need to be removed from a child being raised as a boy. The most common scenario is accidental discovery of persistent Müllerian derivatives or a small uterus during abdominal surgery of a normal boy for cryptorchidism, appendectomy, or bowel disease. Removal would not involve genital surgery. A rarer indication would be that of a completely virilized XX child with congenital adrenal hyperplasia (Prader stage 5) being raised as a male; ovaries and uterus must be removed to prevent breast development and menstruation by early adolescence.

Potential problems: Risks are simply those of abdominal surgery.

Testicular prostheses are saline-filled plastic ovoids implanted in the scrotum. They have no function except to provide the appearance and feel of testes. Several sizes are available, but most are implanted in adolescence to avoid repeated procedures to implant larger sizes at puberty. Prostheses made of silastic are no longer available due to safety and perception-of-safety concerns.

Potential problems: Foreign body reactions, rarely with infection or erosion of scrotal skin, are minimal but constitute the most significant complication.

Penile augmentation surgery is surgery intended to enlarge a small penis. Early attempts in the 1950s and 1960s involved constructing a tube of non-erectile flesh extending a small penis but the penis did not function. In recent years a small number of urologists have been offering an augmenation procedure that involves moving outward some of the buried components of the corpora so that the penis protrudes more. The girth is augmented with transplantation of the patient's fat. This procedure is designed to preserve erectile and sexual function without surgically altering the urethra. This type of surgery is not performed on children and primarily produces a small increase in the size of a normal penis, but would be less likely to produce a major functional change in a severe micropenis.

Potential problems: Reabsorption of the fat is common. Scarring resulting in interference with erectile function is less likely but more damaging.

Concealed penis a normal penis buried in suprapubic fat. In most cases, when the fat is depressed with the fingers, the penis is seen to be of normal size. This is common in overweight boys before the penile growth of puberty. Surgical techniques have been devised to improve it.[16]

Potential problems: The most common difficulty is recurrence with further weight gain. Scarring can occur.

Feminizing surgical procedures

In the last 50 years, the following procedures were most commonly performed for the following intersex conditions and birth defects in order to make the genitalia more like those of normal females:

There are rarer causes of virilization of genetic females or undervirililizaton of genetic males (see intersex for a fuller list), as well as some less easily categorized types of intersex conditions or other malformations of the genitalia. In the last decade, feminizing surgery to support reassignment of genetic males with non-ambiguous micropenis has been largely discontinued, and surgical reassignment of genetic males with exstrophy or other severe malformations or injuries is diminishing. See history of intersex surgery.

Clitorectomy amputation or removal of most of the clitoris, including glans, erectile tissue, and nerves. This procedure was the most common clitoral surgery performed prior to 1970, but was largely abandoned by 1980 because it usually resulted in loss of clitoral sensation.

Potential problems: The primary effect of this surgery, not surprisingly, is a drastic reduction in ability to experience orgasm. The appearance is not very normal. Regrowth of unwanted erectile tissue has sometimes presented problems.

Clitoroplasty, like phalloplasty, is a term that encompasses any surgical reconstruction of the clitoris, such as removal of the corpora. Clitoral recession and reduction can both be referred to as clitoroplasty.

Potential problems: Major complications can include scarring, contractures, loss of sensation, loss of capacity for orgasm, and unsatisfactory appearance.

Clitoral recession involves the repositioning of the erectile body and glans of the clitoris farther back under the symphysis pubis and/or skin of the preputium and mons. This was commonly done from the 1970s through the 1980s to reduce protrusion without sacrificing sensation. Outcomes were often unsatisfactory, and it fell into disfavor in the last 15 years.[17]

Potential problems:Unfortunately the subsequent sensations were not always pleasant, and erection could be painful. Adults who had a clitoral recession in early childhood often report reduced capacity for enjoyment of sexual intercourse, though similar women who had not had surgery also report a high rate of sexual dysfunction.[18]

Clitoral reduction was developed in the 1980s to reduce size without reducing function. Lateral wedges of the erectile tissue of the clitoris are removed to reduce the size and protrusion. The neurovascular tissue is carefully spared to preserve function and sensation. Nerve stimulation and sensory responses are now often performed during the surgery to confirm function of the sensory nerves.[17][19]

Potential problems: The degree to which the goal of preserving sexual sensations is attained is a subject of controversy regarding the necessity of such treatments, and lack of firm evidence of good outcomes.[2][4] Cheryl Chase of the now defunct Intersex Society of North America cautions that even documentation of clitoral nerve function during surgery does not ensure normal sexual function later.[19]

Vaginoplasty, the construction or reconstruction of a vagina, can be fairly simple or quite complex, depending on the initial anatomy. If a normal internal uterus, cervix and upper vagina (the Müllerian derivatives) exist, and the outer virilization is modest, surgery involves separating the fused labia and widening the vaginal introitus. With greater degrees of virilization, the major challenge of the procedure is to provide a passage connecting the outer vaginal opening to the cervix which will stay wide enough to allow coitus. XY girls or women with partial androgen insensitivity syndrome will have a blind vaginal pouch of varying degrees of depth. Sometimes this can be dilated to a usable depth. Sometimes surgery is performed to deepen it.

The most challenging surgery with the highest complication rate is construction of an entirely new vagina (a "neovagina"). The most common instance of this is when a child will be assigned and raised as a female despite complete virilization, as with Prader 5 CAH, or (in the past) when a genetic male infant with a severely defective penis was reassigned as a female. One method is to use a segment of colon, which provides a lubricated mucosal surface as a substitute for the vaginal mucosa. Another is to line the new vagina with a skin graft.[20][21][22]

Potential problems: Stenosis (narrowing) of the constructed vagina is the most common long-term complication and the chief reason that a revision may be required when a girl is older. When a neovagina is made from a segment of bowel, it tends to leak mucus; when made with a skin graft, lubrication is necessary. Less common complications include fistulas, uncomfortable scarring, and problems with urinary continence.[18][23][24]

Gonadectomy is removal of the gonads. If the gonads are dysgenetic testes or streak gonads and at least some of the cells have a Y chromosome, the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing gonadoblastoma. If the gonads are relatively "normal" testes, but the child is to be assigned and raised as female, (e.g., for intersex conditions with severe undervirilization, or major malformations involving an absent or unsalvageable penis) they must be removed before puberty to prevent virilization from rising testosterone. Testes in androgen insensitivity are a special case: if there is any degree of responsiveness to testosterone, they should be removed before puberty. On the other hand, if androgen insensitivity is complete, the testes may be left to produce estradiol (via testosterone) to induce breast development, but there is a slowly increasing risk of cancer in adult life. Streak gonads without a Y chromosome cell line need not be removed but will not function. Finally, the gonads in true hermaphroditism must be directly examined; atypical gonads with Y line or potential testicular function should be removed but in rare instances a surgeon may try to preserve the ovarian part of an ovotestis.[25]

Potential problems: Gonadectomy involves little risk beyond that of any abdominal surgery.

Cloacal exstrophy and bladder exstrophy repair is needed regardless of the sex of assignment or rearing. Simple bladder exstrophy in a genetic female does not usually involve the vagina. Cloacal exstrophy in a genetic female usually requires major surgical reconstruction of the entire perineum, including bladder, clitoris, symphysis pubis, and both the vaginal introitus and urethra. However, the uterus and ovaries are normally formed. Severe bladder exstrophy or cloacal exstrophy in genetic males often renders the phallus widely split, small, and unsalvageable. The scrotum is also widely split, though testes themselves are usually normal. From the 1960s until the last decade, many of these infants were assigned and raised as females, with fashioning of a vagina and gonadectomy as part of the perineal reconstruction.[15]

Potential problems:Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term colostomy or vesicostomy. Creating a functional urethra is difficult and poor healing, with scarring, stricture, or fistula can require a vesicostomy to prevent urinary incontinence. Construction of a functional internal and external anal sphincter can be equally difficult when this has been disrupted as well. Functional problems can warrant a temporary or long-term colostomy. The added challenge for the most severely affected genetic females, and for genetic males who are being raised as females, is construction of a neovagina. Scarring is extensive and the lower torso disfigured even with the best outcomes. Finally, it has become apparent in recent years that some genetic males (without intersex conditions) who are reassigned and raised as females have not developed a female gender identity and have sought reassignment back to male.[26]

Controversies and unsettled questions

Management practices for intersex conditions have evolved over the last 50 years. In the last decade several of the surgical practices have become the subject of public and professional controversy. See History of intersex surgery and Intersex human rights for more detail.

Is functional outcome better when surgery is performed in infancy, in adolescence, or adulthood, for vaginoplasty for markedly virilized females (e.g., from congenital adrenal hyperplasia, mixed gonadal dysgenesis, or partial androgen insensitivity)?

Do any advantages of infant clitoral reduction surgery outweigh the potential disadvantages of reduced or distorted sexual sensation? Clitoral reduction is rarely done except in combination with vaginoplasty when substantial virilization is present.

Should surgery be used as a means of minimizing gender identity issues? Historically this has been problematized, but human rights institutions question such approaches as being "informed by redundant social constructs around gender and biology"[28] Is it valid to assume in cases of ambiguous genitalia that the magnitude of the "innate" tendency to develop a specific gender identity is usually similar to the degree of genital virilization? Should we abandon completely the idea that an unambiguous XY child with an irreparably defective penis might be better off raised as a girl?

Within the last decade, some people have raised the question of whether early surgery to correct atypical genitalia should be done at all, especially for purposes of changing appearance. Opponents of all "corrective surgery" on atypical sex characteristics 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'. Others argue that the key question is one of consent.

Human rights issues

Main article: Intersex human rights

The Council of Europe highlights several areas of concern in relation to intersex surgeries and other medical treatment:

The Council of Europe argues that secrecy and shame have perpetuated human rights abuses and a lack of social understanding of the reality of intersex people. It calls for respect for "intersex persons' right not to undergo sex assignment treatment".[6]

Alice Dreger, a US professor of Clinical Medical Humanities and Bioethics, argues that little has changed in actual clinical practice in recent years.[30] Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and "recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences".[31]

Institutions like the Swiss National Advisory Commission on Biomedical Ethics,[3] the Australian Senate,[4] the Council of Europe,[6][32] World Health Organisation,[1][33] and UN Office of the High Commissioner for Human Rights[34] and Special Rapporteur on Torture[35] have all published reports calling for changes to clinical practice.

In 2011, Christiane Völling won the first successful case brought against a surgeon for non-consensual surgical intervention. The Regional Court of Cologne, Germany, awarded her €100,000.[5]

In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations.[7][8][9][10][11]

See also

Notes

  1. 1 2 World Health Organization (2015). Sexual health, human rights and the law. Geneva: World Health Organization. ISBN 9789241564984.
  2. 1 2 Submission 88 to the Australian Senate inquiry on the involuntary or coerced sterilisation of people with disabilities in Australia, Australasian Paediatric Endocrine Group (APEG), 27 June 2013
  3. 1 2 3 Swiss National Advisory Commission on Biomedical Ethics NEK-CNE (November 2012). On the management of differences of sex development. Ethical issues relating to "intersexuality".Opinion No. 20/2012 (PDF). 2012. Berne.
  4. 1 2 3 4 Australian Senate; Community Affairs References Committee (October 2013). Involuntary or coerced sterilisation of intersex people in Australia. Canberra: Community Affairs References Committee. ISBN 9781742299174.
  5. 1 2 Zwischengeschlecht (December 17, 2015). "Nuremberg Hermaphrodite Lawsuit: Michaela "Micha" Raab Wins Damages and Compensation for Intersex Genital Mutilations!" (text). Retrieved 2015-12-21.
  6. 1 2 3 4 Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
  7. 1 2 Cabral, Mauro (April 8, 2015). "Making depathologization a matter of law. A comment from GATE on the Maltese Act on Gender Identity, Gender Expression and Sex Characteristics". Global Action for Trans Equality. Retrieved 2015-07-03.
  8. 1 2 OII Europe (April 1, 2015). "OII-Europe applauds Malta's Gender Identity, Gender Expression and Sex Characteristics Act. This is a landmark case for intersex rights within European law reform". Retrieved 2015-07-03.
  9. 1 2 Carpenter, Morgan (April 2, 2015). "We celebrate Maltese protections for intersex people". Organisation Intersex International Australia. Retrieved 2015-07-03.
  10. 1 2 Star Observer (2 April 2015). "Malta passes law outlawing forced surgical intervention on intersex minors". Star Observer.
  11. 1 2 Reuters (1 April 2015). "Surgery and Sterilization Scrapped in Malta's Benchmark LGBTI Law". The New York Times.
  12. ↑ Glassberg KI. Editorial: gender assignment and the pediatric urologist. J Urol 161:1308-10, 1999.
  13. ↑ Barbagli, Guido; Sansalone, Salvatore; Djinovic, Rados; Lazzeri, Massimo (2012). "Surgical Repair of Late Complications in Patients Having Undergone Primary Hypospadias Repair during Childhood: A New Perspective". Advances in Urology 2012: 1–5. doi:10.1155/2012/705212. ISSN 1687-6369. Retrieved 2015-07-19.
  14. ↑ Carmack, Adrienne; Notini, Lauren; Earp, Brian (2015). "Should Surgery for Hypospadias Be Performed Before an Age of Consent?". Journal of Sex Research. in press: 1–12. doi:10.1080/00224499.2015.1066745.
  15. 1 2 Schober JM, Carmichael PA, Hines M, Ransley PG (2002). "The ultimate challenge of cloacal exstrophy". J Urol 167: 300–4. doi:10.1016/s0022-5347(05)65455-9.
  16. ↑ Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC (1999). "Concealed penis in childhood: a spectrum of etiology and treatment". J Urol 162: 1165–8. doi:10.1016/s0022-5347(01)68114-x.
  17. 1 2 Rangecroft L, Brain C, Creighton S, Di Ceglie D, Ogilvy-Stuart A, Malone P, Turnock R. Statement of the British Association of Pediatric Surgeons Working Party on the Surgical Management of Children Born with Ambiguous Genitalia. July 2001.
  18. 1 2 Minto CL, Liao L-M, Woodhouse CRJ, Ransley PG, Creighton SM (2003). "The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study". Lancet 361: 1252–7. doi:10.1016/s0140-6736(03)12980-7.
  19. 1 2 Chase C. Re: Measurement of pudendal evoked potentials during feminizing genitoplasty: technique and applications (letter). J Urol 156:1139-40, 1996.
  20. ↑ Creighton S (2001). "Surgery for intersex". J Royal Soc Med 94: 218–20.
  21. ↑ Rink RC, Adams MC (1998). "Feminizing genitoplasty: state of the art". World J Urol 16: 212–218. doi:10.1007/s003450050055.
  22. ↑ Schnitzer JJ, Donahoe PK (2001). "Surgical treatment of congenital adrenal hyperplasia". Endocrinol Metab Clin N Am 30: 137–54. doi:10.1016/s0889-8529(08)70023-9.
  23. ↑ Alizai NK, Thomas DFM, Lilford RJ, Batchelor AGG, Johnson N (1999). "Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty?". J Urol 161: 1588–91. doi:10.1016/s0022-5347(05)68986-0.
  24. ↑ Lobe TE, Woodall DL, Richards GE, Cavallo A, Meyer WJ (1987). "The complications of surgery for intersex: changing patterns over two decades". J Pediatr Surg 22: 651–2. doi:10.1016/s0022-3468(87)80119-7.
  25. ↑ Manuel M, Katayama PK, Jones HW. "Jr. 1976 The age of occurrence of gonadal tumors in intersex patients with a Y chromosome". Am J Obstet Gynecol 124: 293–300.
  26. 1 2 Reiner WG, Gearhart JP (2004). "Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex after birth". New Engl J Med 350: 333–41. doi:10.1056/nejmoa022236.
  27. ↑ Melton L (2001). "New perspectives on the management of intersex". Lancet 357: 2110. doi:10.1016/s0140-6736(00)05240-5. A recent journalist’s summary of the controversies. Letters exchanged in response demonstrate arguments from professionals on both sides of the arguments and complexity of some of the issues. E.g., in response to argument against clitoral reduction surgery, a girl who will not swim at school because her clitoris is visibly prominent is described.
  28. ↑ Australian Human Rights Commission (June 2015). Resilient Individuals: Sexual Orientation, Gender Identity & Intersex Rights. Sydney: Australian Human Rights Commission. ISBN 978-1-921449-71-0.
  29. ↑ Houk, C. P.; Hughes, I. A.; Ahmed, S. F.; Lee, P. A.; Writing Committee for the International Intersex Consensus Conference Participants (August 2006). "Summary of Consensus Statement on Intersex Disorders and Their Management". Pediatrics 118 (2): 753–757. doi:10.1542/peds.2006-0737. ISSN 0031-4005. Retrieved 2015-07-19.
  30. ↑ Dreger, Alice (April 3, 2015). "Malta Bans Surgery on Intersex Children". The Stranger SLOG.
  31. ↑ Creighton, Sarah M.; Michala, Lina; Mushtaq, Imran; Yaron, Michal (January 2, 2014). "Childhood surgery for ambiguous genitalia: glimpses of practice changes or more of the same?". Psychology and Sexuality 5 (1): 34–43. doi:10.1080/19419899.2013.831214. ISSN 1941-9899. Retrieved 2015-07-19.
  32. ↑ Resolution 1952/2013, Provision version, Children’s right to physical integrity, Council of Europe, 1 October 2013
  33. ↑ Eliminating forced, coercive and otherwise involuntary sterilization, An interagency statement, World Health Organization, May 2014.
  34. ↑ United Nations High Commissioner for Human Rights (May 4, 2015), Discrimination and violence against individuals based on their sexual orientation and gender identity
  35. ↑ Report of the UN Special Rapporteur on Torture, Office of the UN High Commissioner for Human Rights, February 2013.

References

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