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The Brussels Collaboration On Bodily Integrity. Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-50. [PMID: 39018160 DOI: 10.1080/15265161.2024.2353823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
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Carpenter M, Kraus C, Earp BD. "Should we correct hypospadias during childhood?" A question of facts and values. J Pediatr Urol 2024; 20:432-433. [PMID: 38355383 DOI: 10.1016/j.jpurol.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Morgan Carpenter
- School of Public Health, Sydney Health Ethics, The University of Sydney, Australia
| | - Cynthia Kraus
- Faculty of Social and Political Sciences, University of Lausanne, Switzerland
| | - Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
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Özbey H. Satisfaction/happiness after hypospadias repair and penile beauty - Comment on "Should we correct hypospadias during childhood? Decision Regret and Quality of Life Assessment (DRAQULA) study". J Pediatr Urol 2024; 20:427-428. [PMID: 38246814 DOI: 10.1016/j.jpurol.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Hüseyin Özbey
- Department of Pediatric Surgery, Division of Pediatric Urology and Andrology, Sechenov First Moscow State Medical University, Moscow, Russia; Tunaboylu Sok. Deniz Apt. No.17/3, Bakırköy, 34147, İstanbul, Turkey.
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Carpenter M, Kraus C, Earp BD. Reply to Hadidi. J Pediatr Urol 2024; 20:435-436. [PMID: 38458922 DOI: 10.1016/j.jpurol.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Morgan Carpenter
- School of Public Health, Sydney Health Ethics, The University of Sydney, Australia
| | - Cynthia Kraus
- Faculty of Social and Political Sciences, University of Lausanne, Switzerland
| | - Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
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Neheman A, Schwarztuch Gildor O, Shumaker A, Beberashvili I, Bar-Yosef Y, Arnon S, Zisman A, Stav K. Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair. CHILDREN (BASEL, SWITZERLAND) 2024; 11:189. [PMID: 38397301 PMCID: PMC10887056 DOI: 10.3390/children11020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported. OBJECTIVE To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations. MATERIALS AND METHODS This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57. RESULTS The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis. CONCLUSIONS Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.
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Affiliation(s)
- Amos Neheman
- Meir Medical Center, Department of Urology, Kfar Saba 44281, Israel; (A.N.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
| | - Omri Schwarztuch Gildor
- Meir Medical Center, Department of Urology, Kfar Saba 44281, Israel; (A.N.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
| | - Andrew Shumaker
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
| | - Ilia Beberashvili
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Nephrology, Zerifin 703001, Israel
| | - Yuval Bar-Yosef
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Shmuel Arnon
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Meir Medical Center, Department of Neonatology, Kfar Saba 4428164, Israel
| | - Amnon Zisman
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
| | - Kobi Stav
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
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