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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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Wirmer J, Fawzy M, Sennert M, Hadidi AT. Should we correct hypospadias during childhood? Decision Regret And QUality of Life Assessment (DRAQULA) study. J Pediatr Urol 2024; 20:421-426. [PMID: 38145916 DOI: 10.1016/j.jpurol.2023.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/27/2023]
Abstract
AIM OF THE WORK To evaluate patient's satisfaction, Decision Regret And QUality of Life Assessment (DRAQULA) among adolescents (older than 15 years) and adults after hypospadias surgery in childhood. PATIENTS AND METHODS 234 Patients operated on hypospadias as children in our center and their parents were contacted after they reached the age of 15 years to complete a questionnaire survey to assess satisfaction with the operative result, the regret with the operative decision and the health related quality of life (HRQOL). The survey is based on the Decision Regret Scale available in the literature with a score of 100 meaning maximum dissatisfaction or regret, and on the Kidscreen10 index. Satisfaction was measured on a scale from 1 to 5 with 5 signifying full satisfaction. RESULTS 81 of 234 patients from 15 to 43 years (mean age 19.7 years) completed the survey (34.6 %). 44 Patients had distal, and 17 proximal hypospadias and the remaining 20 patients could not remember the type of hypospadias they had. The patient's satisfaction with the operative result was 5 (full satisfaction) in 74.1 %, 4 in 18.5 %, 3 in 6.2 % and 2 in 1.2 % (mean satisfaction score 4.7 of 5). Regarding decision regret among patients, 64/81 patients (79.0 %) had no decision regret. Only 14.8 % reported mild and 6.2 % moderate decisional regret (mean decisional regret score 4.8). 71 of 234 parents answered the parents' questionnaire (30.0 %). Fifty-eight (81.7 %) had no decision regret. 13 parents (18.3 %) had decision regret; 10 parents (14.1 %) reported mild, 2 parents (2.8 %) moderate, and only one parent (1.4 %) reported strong decisional regret. The mean HRQOL T-score was 55.9 (SD 10, control Group of adolescent males from 12 to 18 years.) and thus corresponded to the average of the reference normal population. DISCUSSION In this study, only 19.7 % had decision regret as compared to 50-65 % reported in literature. The decision regret scale of O'Connor needs to be revalidated as even candidates who approve of the decision of early surgery have a score less than 25 and considered to have decision regret. CONCLUSION The results of the survey showed that 90 % of the patients were satisfied with early hypospadias surgery with average HRQOL and low level of decisional regret in patients as well as parents. The findings support the current practice of operating hypospadias in early childhood.
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Affiliation(s)
- Johannes Wirmer
- Hypospadias Center, Pediatric Surgery Department, Sana Klinikum, Offenbach, Germany
| | - Mohamed Fawzy
- Hypospadias Center, Pediatric Surgery Department, Sana Klinikum, Offenbach, Germany
| | - Michael Sennert
- Hypospadias Center, Pediatric Surgery Department, Sana Klinikum, Offenbach, Germany
| | - Ahmed T Hadidi
- Hypospadias Center, Pediatric Surgery Department, Sana Klinikum, Offenbach, Germany.
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Morris B, Rivin BE, Sheldon M, Krieger JN. Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review. Cureus 2024; 16:e54772. [PMID: 38405642 PMCID: PMC10889534 DOI: 10.7759/cureus.54772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Contrasting ethical and legal arguments have been made concerning neonatal male circumcision (NMC) that merit the first systematic review on this topic. We performed PRISMA-compliant keyword searches of PubMed, EMBASE, SCOPUS, LexisNexis, and other databases and identified 61 articles that met the inclusion criteria. In the bibliographies of these articles, we identified 58 more relevant articles and 28 internet items. We found high-quality evidence that NMC is a low-risk procedure that provides immediate and lifetime medical and health benefits and only rarely leads to later adverse effects on sexual function or pleasure. Given this evidence, we conclude that discouraging or denying NMC is unethical from the perspective of the United Nations Convention on the Rights of the Child, which emphasizes the right to health. Further, case law supports the legality of NMC. We found, conversely, that the ethical arguments against NMC rely on distortions of the medical evidence. Thus, NMC, by experienced operators using available safety precautions, appears to be both legal and ethical. Consistent with this conclusion, all of the evidence-based pediatric policies that we reviewed describe NMC as low-risk and beneficial to public health. We calculated that a reduction in NMC in the United States from 80% to 10% would substantially increase the cases of adverse medical conditions. The present findings thus support the evidence-based NMC policy statements and are inconsistent with the non-evidence-based policies that discourage NMC. On balance, the arguments and evidence reviewed here indicate that NMC is a medically beneficial and ethical public health intervention early in life because it reduces suffering, deaths, cases, and costs of treating adverse medical conditions throughout the lifetimes of circumcised individuals.
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Affiliation(s)
- Brian Morris
- Faculty of Medicine and Health, The University of Sydney, Sydney, AUS
| | - Beth E Rivin
- Schools of Medicine and Public Health, Department of Global Health, University of Washington, Seattle, USA
- Bioethics, Uplift International, Seattle, USA
| | - Mark Sheldon
- Medical Humanities and Bioethics Program, Feinberg School of Medicine, Chicago, USA
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Beland LE, Reifsnyder JE, Palmer LS. The diversity of hypospadias management in North America: a survey of pediatric urologists. World J Urol 2023; 41:2775-2781. [PMID: 37707567 DOI: 10.1007/s00345-023-04568-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
PURPOSE To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America. METHODS An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology. RESULTS The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia. CONCLUSIONS Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.
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Affiliation(s)
- Leah E Beland
- Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Jennifer E Reifsnyder
- Division of Pediatric Urology, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, 321 Crossways Park Drive, Woodbury, New York, 11797, USA
| | - Lane S Palmer
- Division of Pediatric Urology, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, 321 Crossways Park Drive, Woodbury, New York, 11797, USA.
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Wood D, Wilcox D. Hypospadias: lessons learned. An overview of incidence, epidemiology, surgery, research, complications, and outcomes. Int J Impot Res 2023; 35:61-66. [PMID: 35352016 DOI: 10.1038/s41443-022-00563-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/09/2022]
Abstract
Hypospadias is a common condition and familiar, though sometimes challenging territory for the pediatric urologist. This review is a summary of hypospadias incidence, epidemiology, surgery, research, and complications intended for the non-specialist. It outlines the history, the principles of surgery for hypospadias, and the long-term outcomes.
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Affiliation(s)
- Dan Wood
- University of Colorado, Aurora, CO, USA. .,Center for Childrens' Surgery Children's Hospital Colorado, Aurora, CO, USA.
| | - Duncan Wilcox
- Center for Childrens' Surgery Children's Hospital Colorado, Aurora, CO, USA
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On becoming autonomous and "coercive cultural acts": a reply to Max Buckler. Int J Impot Res 2023; 35:35-37. [PMID: 36163463 DOI: 10.1038/s41443-022-00617-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/08/2022]
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Child genital cutting and surgery across cultures, sex, and gender. Part 1: female, male, intersex-and trans? The difficulty of drawing distinctions. Int J Impot Res 2023; 35:1-5. [PMID: 36460787 DOI: 10.1038/s41443-022-00639-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022]
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Berry AW, Monro S. Ageing in obscurity: a critical literature review regarding older intersex people. Sex Reprod Health Matters 2022; 30:2136027. [DOI: 10.1080/26410397.2022.2136027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeline W. Berry
- Marie Curie Research Fellow, University of Huddersfield, Huddersfield, UK. Correspondence:
| | - Surya Monro
- Professor of Sociology and Social Policy, University of Huddersfield, Huddersfield, UK
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DARWISH AS, ELNAGGAR OA, ZAKI AA, KAMEL NM, DAHAB MM, EL-SAYEM K. Role of autologous platelet rich plasma in hypospadias repair. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.20.05217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term Complications of Hypospadias Repair. CURRENT SEXUAL HEALTH REPORTS 2022. [DOI: 10.1007/s11930-022-00336-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Referral patterns, clinical features and management of uncorrected hypospadias in a series of adult men. J Pediatr Urol 2022; 18:480.e1-480.e7. [PMID: 35773150 DOI: 10.1016/j.jpurol.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/27/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hypospadias surgery undertaken in early life often continues to impose challenges as patients age. Little is known about the natural history of uncorrected hypospadias persisting into adulthood. OBJECTIVE To describe presenting symptoms and management strategies in men with uncorrected hypospadias referred to our national tertiary transitional clinic for congenital urological conditions. MATERIALS AND METHODS Patients with uncorrected hypospadias older than 16 years at the time of referral were identified by searching the electronic patient record system for ICD-10 hypospadias codes. Data were extracted over a 10-year period according to a predefined protocol. RESULTS Among 201 referrals, 65 men with hypospadias (glanular n = 12, coronal n = 26, subcoronal n = 9, corporal n = 4, penoscrotal n = 2 and MIP n = 12) had never previously had reconstructive surgery undertaken. Obstructive symptoms predominated (n = 30) and the risk of symptoms increased with advancing age (Figure). Presenting complaints varied across the age span; cosmetic issues (n = 11) and coital pain (n = 5) were primarily seen in youth as opposed to urinary obstructive symptoms that were increasingly more frequent with age (p = 0.002) (Figure). Management included reconstructive surgery (n = 24), minor procedures (preputioplasty, circumcision, meatoplasty, dilatation/urethrotomy, total n = 28) as well as counselling (n = 12). The management strategies were independent of age and hypospadias type. DISCUSSION The current cohort delineates the dynamic nature of hypospadias in itself. We speculate that the distinction in the primary complaint leading to referral between the extremes of age may relate to the vanity and insecurity of youth while older patients first come forward when other symptoms arise. Dissatisfaction with genital appearance is uncommon in previous smaller studies on men with uncorrected hypospadias unlike in our study, where 11 patients were assessed mainly for cosmetic concerns. Obstruction is the main symptom encountered in adult hypospadias patients operated in early life, and a similar picture was observed in our cohort of unoperated cases. Urethral dilatation and internal urethrotomy are temporizing procedures but were successful in immediate alleviation of obstructive symptoms in patients not willing to consign themselves to formal surgery. The study is limited by its retrospective design, and our symptomatic cohort may also represent the extreme end of the hypospadias spectrum. CONCLUSION Medical issues vary across the age span in men with unrepaired hypospadias. Minor surgical procedures as well as counselling play an equally important role as reconstructive hypospadias surgery in the management of unrepaired hypospadias in adulthood.
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Vavilov S, Roberts E, Smith GHH, Starkey M, Pockney P, Deshpande AV. Parental decision regret among Australian parents after consenting to or refusing hypospadias repair for their son: Results of a survey with controls. J Pediatr Urol 2022; 18:482-488. [PMID: 35659825 DOI: 10.1016/j.jpurol.2022.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/03/2022] [Accepted: 04/30/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Parental decision regret in hypospadias surgery is a recognised source of long-lasting psycho-social morbidity. High parental decision regret after their child's hypospadias repair is reported. The aim of this study is to report on decision regret in Australian parents, who accepted and declined surgery for their son and explore underlying factors for decision-making, satisfaction, and regret. MATERIALS AND METHODS An online anonymous survey was administered to three groups of parents: 1) parents who consented for hypospadias repair, 2) parents who declined repair and 3) a control group who requested circumcision for their child. Operations occurred between 2010 and 2020 in two paediatric hospitals in New South Wales, Australia. The survey included a validated decision regret assessment tool and additional questions to explore the possible basis of the opinions. RESULTS One hundred and eighteen parents (invited - 381, completed - 116, response rate - 31%) participated in the survey. Decision regret was present in group 1 (n = 89) - 55% (moderate-to-severe 15%), in group 2 (n = 14) - 71% (moderate-to-severe 57%), and in the control group (n = 15) - 15% (moderate-to-severe 8%) of parents. There was a significant difference in the median decision regret score between all three groups. Parents who chose hypospadias repair were mostly concerned about function. CONCLUSIONS The prevalence of decision regret among Australian parents who consented for their son's hypospadias repair was lower compared with the mean decision regret reported in the literature to date (55% vs 65%). Decision regret and its severity were highest among parents who declined hypospadias repair. New strategies are needed to reduce decision regret in parents whether they elect for surgery or not.
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Affiliation(s)
- Sergey Vavilov
- School of Medicine and Public Health, The University of Newcastle, NSW, Australia; Urology Unit, Department of Surgery, The Children's Hospital at Westmead, NSW, Australia.
| | - Elysa Roberts
- Department of Occupational Therapy, School of Health Sciences, The University of Newcastle, NSW, Australia.
| | - Grahame H H Smith
- Urology Unit, Department of Surgery, The Children's Hospital at Westmead, NSW, Australia; Department of Paediatrics and Child Health, The University of Sydney, NSW, Australia.
| | - Malcolm Starkey
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Research Alliance, Melbourne, VIC, Australia; School of Biomedical Sciences and Pharmacy, College of Health and Well Being, The University of Newcastle, NSW, Australia.
| | - Peter Pockney
- School of Medicine and Public Health, The University of Newcastle, NSW, Australia; Discipline of Surgery, Medical School, The University of Western Australia, Perth, Australia.
| | - Aniruddh V Deshpande
- School of Medicine and Public Health, The University of Newcastle, NSW, Australia; Urology Unit, Department of Surgery, The Children's Hospital at Westmead, NSW, Australia; Faculty of Medicine, The University of Sydney, NSW, Australia.
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Charron M, Saulnier K, Palmour N, Gallois H, Joly Y. Intersex Stigma and Discrimination: Effects on Patient-Centred Care and Medical Communication. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1089782ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Parental decisional regret after surgical treatment in young boys born with hypospadias. J Pediatr Urol 2021; 17:691.e1-691.e7. [PMID: 34305009 DOI: 10.1016/j.jpurol.2021.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias. METHODS Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret. RESULTS Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret. CONCLUSIONS A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.
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Bennecke E, Bernstein S, Lee P, van de Grift TC, Nordenskjöld A, Rapp M, Simmonds M, Streuli JC, Thyen U, Wiesemann C. Early Genital Surgery in Disorders/Differences of Sex Development: Patients' Perspectives. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:913-923. [PMID: 33712989 PMCID: PMC8035116 DOI: 10.1007/s10508-021-01953-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 05/04/2023]
Abstract
Controversy continues over a proposed moratorium on elective genital surgery in childhood for disorders/differences of sex development (DSD). Empirical evidence on patient preference is needed to inform decision-making. We conducted a multicentre survey by cross-sectional questionnaire in 14 specialized clinics in six European countries. The sample comprised 459 individuals (≥ 16 years) with a DSD diagnosis, including individuals with congenital adrenal hyperplasia (CAH) (n = 192), XY DSD with prenatal androgen effect (A) (n = 150), and without (nA) (n = 117). Main outcome measures were level of agreement with given statements regarding genital surgery, including clitoris reduction, vaginoplasty, and hypospadias repair. A total of 66% of individuals with CAH and 60% of those with XY DSD-A thought that infancy or childhood were the appropriate age for genital surgery. Females with XY DSD were divided on this issue and tended to prefer vaginoplasty at a later age (XY DSD-A 39%, XY DSD-nA 32%). A total of 47% of males preferred early hypospadias surgery. Only 12% (CAH), 11% (XY DSD-A), and 21% (XY DSD-nA) thought they would have been better off without any surgery in childhood or adolescence. Individuals who had early genital surgery were more likely to approve of it. Outcome data failed to support a general moratorium on early elective genital surgery. Participant perspectives varied considerably by diagnostic category, gender, history of surgery, and contact with support groups. Case-by-case decision-making is better suited to grasping the ethical complexity of the issues at stake.Trial registration: German Clinical Trials Register DRKS00006072.
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Affiliation(s)
- Elena Bennecke
- Department of Paediatric Endocrinology and Diabetology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Sozialpädiatrisches Zentrum, Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stephanie Bernstein
- Department of Paediatrics, Göttingen University Medical Center, Göttingen, Germany
| | - Peter Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center (VUmc), Amsterdam, The Netherlands
- Department of Medical Psychology and Sexology, Amsterdam University Medical Center, Amsterdam (VUmc), The Netherlands
| | - Agneta Nordenskjöld
- Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, and Center of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marion Rapp
- Klinik für Kinder- und Jugendmedizin, Universität zu Lubeck, Lubeck, Germany
| | | | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin, Universität zu Lubeck, Lubeck, Germany
| | - Claudia Wiesemann
- Department of Medical Ethics and History of Medicine, Göttingen University Medical Center, Humboldtallee 36, 37073, Göttingen, Germany.
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Earp BD, Shahvisi A, Reis-Dennis S, Reis E. The need for a unified ethical stance on child genital cutting. Nurs Ethics 2021; 28:1294-1305. [PMID: 33719736 DOI: 10.1177/0969733020983397] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and other largely US-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to "health benefits" as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a "loophole" through which certain forms of female genital cutting-or female genital "mutilation" as it is defined by the World Health Organization-could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward female genital "mutilation" and so-called intersex genital "normalization" surgeries (i.e. surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations-including the American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and World Health Organization-to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.
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Earp BD. Male or female genital cutting: why 'health benefits' are morally irrelevant. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106782. [PMID: 33462078 DOI: 10.1136/medethics-2020-106782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 06/12/2023]
Abstract
The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has 'no health benefits', male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own 'private' anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
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Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT 06511, USA
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Arulanandam B, Dorais M, Li P, Poenaru D. The burden of waiting: wait times for pediatric surgical procedures in Quebec and compliance with national benchmarks. Can J Surg 2021; 64:E14-E22. [PMID: 33412000 PMCID: PMC7955833 DOI: 10.1503/cjs.020619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Wait time information and compliance with national guidelines are limited to a few adult conditions in the province of Quebec. We aimed to assess compliance with Paediatric Canadian Access Targets for Surgery (P-CATS) guidelines and determine the burden incurred due to waiting for 3 common elective surgical conditions (inguinal hernia, cryptorchidism and hypospadias) in a pediatric population. Methods We carried out a population-based retrospective cohort study of randomly selected children residing in Quebec without complex chronic medical conditions, using administrative databases belonging to the Régie de l’assurance maladie du Québec for the period 2010–2013. Disability-adjusted life years (DALYs) were calculated to measure the burden due to waiting. Multivariate forward regression identified risk factors for compliance with national guidelines. Results Surgical wait time information was assessed for 1515 patients, and specialist referral wait time was assessed for 1389 patients. Compliance with P-CATS benchmarks was 76.6% for seeing a specialist and 60.7% for receiving surgery. Regression analysis identified older age (p < 0.0001) and referring physician specialty (p = 0.001) as risk factors affecting specialist referral wait time target compliance, whereas older age (p = 0.040), referring physician specialty (p = 0.043) and surgeon specialty (p = 0.002) were significant determinants in surgical wait time compliance. The total burden accrued due to waiting beyond benchmarks was 35 DALYs. Conclusion Our results show that provincial compliance rates with wait time benchmarks are still inadequate and need improvement. Patient age and physician specialty were both found to have significant effects on wait time target compliance.
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Affiliation(s)
- Brandon Arulanandam
- From McGill University, Montreal, Que. (Arulanandam); StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Que. (Dorais); the Division of General Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Li); and the Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Poenaru)
| | - Marc Dorais
- From McGill University, Montreal, Que. (Arulanandam); StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Que. (Dorais); the Division of General Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Li); and the Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Poenaru)
| | - Patricia Li
- From McGill University, Montreal, Que. (Arulanandam); StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Que. (Dorais); the Division of General Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Li); and the Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Poenaru)
| | - Dan Poenaru
- From McGill University, Montreal, Que. (Arulanandam); StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Que. (Dorais); the Division of General Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Li); and the Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Que. (Poenaru)
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Vavilov S, Smith G, Starkey M, Pockney P, Deshpande AV. Parental decision regret in childhood hypospadias surgery: A systematic review. J Paediatr Child Health 2020; 56:1514-1520. [PMID: 32885548 DOI: 10.1111/jpc.15075] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Abstract
We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.
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Affiliation(s)
- Sergey Vavilov
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Grahame Smith
- Urology Unit, Department of Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Malcolm Starkey
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Priority Research Centre GrowUpWell, Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Pockney
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Aniruddh V Deshpande
- Urology Unit, Department of Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Priority Research Centre GrowUpWell, Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Ethische Aspekte der Versorgung von Kindern mit „disorders/differences of sex development“. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0716-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carpenter M. Intersex Variations, Human Rights, and the International Classification of Diseases. Health Hum Rights 2018; 20:205-214. [PMID: 30568414 PMCID: PMC6293350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Over time, the World Health Organization (WHO) has reviewed and removed pathologizing classifications and codes associated with sexual and gender minorities from the International Classification of Diseases (ICD). However, classifications associated with intersex variations, congenital variations in sex characteristics or differences of sex development, remain pathologized. The ICD-11 introduces additional and pathologizing normative language to describe these as "disorders of sex development." Current materials in the ICD-11 Foundation also specify, or are associated with, unnecessary medical procedures that fail to meet human rights norms documented by the WHO itself and Treaty Monitoring Bodies. This includes codes that require genitoplasties and gonadectomies associated with gender assignment, where either masculinizing or feminizing surgery is specified depending upon technical and heteronormative expectations for surgical outcomes. Such interventions lack evidence. Human rights defenders and institutions regard these interventions as harmful practices and violations of rights to bodily integrity, non-discrimination, equality before the law, privacy, and freedom from torture, ill-treatment, and experimentation. WHO should modify ICD-11 codes by introducing neutral terminology and by ensuring that all relevant codes do not specify practices that violate human rights.
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Affiliation(s)
- Morgan Carpenter
- Senior advisor at GATE, a co-executive director of Intersex Human Rights Australia, and a graduate and PhD candidate in bioethics at Sydney Health Ethics in the Faculty of Medicine and Health, University of Sydney, Australia. This article was produced in the context of the GATE initiative on the process of revision and reform of the International Classification of Diseases
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Earp BD, Sardi LM, Jellison WA. False beliefs predict increased circumcision satisfaction in a sample of US American men. CULTURE, HEALTH & SEXUALITY 2018; 20:945-959. [PMID: 29210334 DOI: 10.1080/13691058.2017.1400104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that 'circumcised' women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut 'do not know what they are missing' and may 'justify' their genitally-altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, greater endorsement of false beliefs concerning circumcision and penile anatomy predicted greater satisfaction with being circumcised, while among genitally intact men, the opposite trend occurred: greater endorsement of false beliefs predicted less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack-of-harm reported by many circumcised men, like the lack-of-harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification.
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Affiliation(s)
- Brian D Earp
- a Departments of Philosophy and Psychology , Yale University , New Haven , CT , USA
| | - Lauren M Sardi
- b Department of Sociology, Criminal Justice, and Anthropology , Quinnipiac University , Hamden , CT , USA
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Abstract
Hypospadias is one of the most common congenital anomalies in men. The condition is typically characterized by proximal displacement of the urethral opening, penile curvature, and a ventrally deficient hooded foreskin. In about 70%, the urethral meatus is located distally on the penile shaft; this is considered a mild form that is not associated with other urogenital deformities. The remaining 30% are proximal and often more complex. In these cases, endocrinological evaluation is advised to exclude disorders of sexual differentiation, especially in case of concomitant unilateral or bilateral undescended testis. Although the etiology of hypospadias is largely unknown, many hypotheses exist about genetic predisposition and hormonal influences. The goal of hypospadias repair is to achieve cosmetic and functional normality, and currently, surgery is recommended between 6 and 18 months of age. Hypospadias can be corrected at any age with comparable complication risk, functional, and cosmetic outcome; however, the optimal age of repair remains conclusive. Although long-term overall outcome concerning cosmetic appearance and sexual function is fairly good, after correction, men may more often be inhibited in seeking sexual contact. Moreover, lower urinary tract symptoms occur twice as often in patients undergoing hypospadias repair and can still occur many years after the initial repair. CONCLUSION This study explores the most recent insights into the management of hypospadias. What is Known: • Guidelines advise referral for treatment between 6 and 18 months of age. • Cosmetic outcome is considered satisfactory in over 70% of all patients. What is New: • Long-term complications include urinary tract symptoms and sexual and cosmetic issues. • New developments allow a more individualized approach, hopefully leading to less complications and more patient satisfaction.
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Affiliation(s)
- H. J. R. van der Horst
- Department of Urology, VUmc, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - L. L. de Wall
- Department of Urology, Radboudumc, Geert Grooteplein 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence. Glob Public Health 2016; 13:626-641. [DOI: 10.1080/17441692.2016.1184292] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Division of Epidemiology and Disease Surveillance, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
| | - Brian D. Earp
- The Hastings Center Bioethics Research Institute, Garrison, NY, USA
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Earp BD. In defence of genital autonomy for children. JOURNAL OF MEDICAL ETHICS 2016; 42:158-63. [PMID: 26792817 DOI: 10.1136/medethics-2015-103030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/02/2015] [Indexed: 05/21/2023]
Abstract
Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate-or even encourage-what the authors regard as 'de minimis' forms of female genital mutilation (as defined by the World Health Organization). In this commentary, I argue that many serious problems would be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision. Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves.
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