Clitoral surgery on minors: an interview study with clinical experts of differences of sex development

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

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.

Differences of sex development and surgical decisions: focus group interviews with health care professionals in Norway

Background

Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals' (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process.

Methods

Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis.

Results

Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child's and caregivers' needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals.

Conclusion

HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents' wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.

A relational approach to youth healthcare: Examining young people's, parents' and clinicians' experiences in the context of variations in sex characteristics

According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts.

Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH)

Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.

Hypospadias surgery: understanding parental emotions, decisions and regrets

This paper builds an argument about genital surgery in the context of medical treatment of children and young people with variations in sex characteristics. First, I set out what is known from existing research including psychological research, surgical follow-up studies and parental regret studies. Second, I present an analysis of surgeons' talk about children, young people and parents in relation to genital surgery. This paper focuses most specifically on hypospadias surgery, but the argumentation is relevant for other kinds of genital surgery carried out in the context of genital variations. The questions guiding this paper are: what research evidence supports hypospadias surgery and what research evidence brings this surgery into question? How might a new interpretation of the evidence, in light of psychosocial research and human rights concerns, contribute to a new perspective on elective genital surgery on minors with variations in sex characteristics? I draw out implications for clinicians supporting parents to decide whether a surgical pathway is the best option for their child.

Gendered genital modifications in critical anthropology: from discourses on FGM/C to new technologies in the sex/gender system

Since the late 19th century, genital modifications (female and male) have been an important research subject in anthropology. According to a comparative and constructivist perspective, they were first interpreted as rites of passage, then as rites of institutions. In a complex dialogue with feminist movements, 20th-century scholars recognised that the cultural meanings of these modifications are multiple and changing in time and space. Conversely, according to WHO, since the 1950s, Female Genital Mutilation or Cutting (FGM/C) has been considered a form of Violence Against Women and Girls (VAWG). Interpreted as VAWG, FGM/C has progressively been isolated from its complementary male rite, selected for special condemnation, and banned. An order of discourse has been built by WHO and other international organisations. This article provides a genealogic deconstruction of the order of discourse lexicon, highlighting dislocations between anthropology and the human rights agenda. Today, genital modifications encompass FGM/C, male circumcision, clitoral reconstruction after FGM/C, gender reassignment surgery, and intersex and 'cosmetic' genital surgery. I propose to call these procedures Gendered Genital Modifications (GGMo). GGMo implicates public health, well-being, potential harm, sexuality, moral and social norms, gender empowerment, gender violence, and prohibitive and permissive policies and laws. The selective production of knowledge on FGM/C has reinforced the social and political polarisation between practices labelled as barbaric and others considered modern, accessible, and empowering. I suggest an anthropological interpretation for the socio-cultural meanings of health, sexuality, purity and beauty. I propose future interdisciplinary studies of how consent, bodily integrity and personal autonomy bear on concepts of agency and subjectivity in the sex/gender system.

Enduring uncertainties. Medical accounts on caring for young people with variations of sex characteristics

Objectives

The diagnosis of intersex or variations of sex characteristics (VSC) often has a big impact on families who fear social stigmatization. Research has shown that intersex populations often experience important health disparities and that poor mental health and daily function are common among youth with VSC. The present study aimed to explore what healthcare professionals of adolescents and young adults (AYA) with VSC find important in terms of care to this group of patients.

Methods

Semi-structured interviews were conducted with Swiss healthcare providers involved in the care of youth born with an intersex variation. The qualitative data were analyzed using reflexive thematic analysis.

Results

Analysis resulted in six major themes: (1) With regard to patients' and families lived experiences, interviewees reported that fertility was as a major issue for parents but not for intersex youth as they were said to live in the moment. (2) Respondents considered various forms of psycho-social care (professional support, peer support and informal support from family and friends) to be of fundamental importance for their patients, but many of them seemed critical about support from advocacy groups and activists. All healthcare providers reported significant gaps in (3) the transition process and (4) the establishment of multidisciplinary care teams due to structural, provider- and patient-related barriers. (5) Participants were in favor of a more holistic and patient-centred care approach and (6) were critical about the medicalized use of DSD (disorder of sex development) with patients and families.

Conclusion

These findings suggest that although clinicians work hard to implement a holistic approach to care, their intentions are often undercut by a desire to hold a position of medical control. Healthcare professionals need to come to see medical uncertainty not only as a threat but also as an opportunity.

Health intervention experiences and associated mental health outcomes in a sample of LGBTQ people with intersex variations in Australia

People with intersex variation/s have sex characteristics determined by reproductive anatomy or chromosomal, gonadal, or hormonal expressions that are not typical of medical and societal norms for male or female bodies and are widely subjected to irreversible medical interventions at an early age to reinforce sex assignment. These interventions may be accompanied by experiences of lack of autonomy for the individual and, at times, lack of fully informed consent on the part of the individual or their parents/carers. People with intersex variations additionally experience high rates of mental health concerns relating to stigma, discrimination and poor healthcare experiences. The intersections between LGBTQ identities and intersex variations are poorly understood but are important given a high proportion of people with intersex variations identify as LGBTQ. This study explored associations between healthcare experiences and mental health outcomes among 46 LGBTQ people aged between 18 and 67 years old with intersex variations in Australia. Findings provide evidence of associations between suicidal thinking, suicidal attempts, depression or anxiety and negative healthcare experiences, including limited autonomy and consent, and challenges accessing psychological support. These highlight the need for further research and proactive intervention to advance human rights and improve health outcomes for this population.

The harms of medicalisation: intersex, loneliness and abandonment

This article develops loneliness as a political and social justice issue by illustrating the harmful personal and social consequences of the medical jurisdiction over and constitution of variations in sex characteristics. Whilst connections between loneliness, health and illness have been well established, this work customarily identifies the ways illness can lead to, or be caused by, loneliness. Instead, I provide an account of the central role of medicalisation and medical management in producing loneliness. By doing so, I underline the imperative for medical practice to consider its influence upon social and personal, as well as physical, wellbeing. Drawing on stories shared through solicited diaries followed by in-depth interviews with seven people with sex variations and two parents in the UK, I show how accounts of loneliness help to illuminate the violence of abandonment, silencing and marginalisation that often goes unheard, together with hidden or normalised systems of harm.

Building on concepts of ethical loneliness and ontological loneliness, I show how structural violations operate to injure trust and self-worth, leading to social unease. I argue for the importance of people with sex variations finding sites of comfort and acceptance, but note the ways that some forms of medicalisation can inhibit alliances and community formation, despite diagnoses also carrying the potential to facilitate informal support structures and collective identities. By bringing together intersex studies with discourses of loneliness, I develop a better understanding of loneliness as a product of social and systemic violence, and the ways in which medical discourses tie in with larger structures of oppression, coercion and control. This article concludes by underlining the need for structural change in our approach to and understanding of sex variations, and with a call for us to become more attentive to these stories of medical harm, to ensure that they are heard and to seek necessary justice.

Decolonising and demedicalising intersex research

In this commentary, we examine the role of non-Indigenous psychology researchers in settler states such as Aotearoa / New Zealand. A key focus is on demedicalising and decolonising intersex. We describe approaches to knowledge production that are based on the decolonising thinking of Indigenous and non-Indigenous researchers, and that open up opportunities for resistance and transformation. We then examine how decolonisation can be brought into dialogue with demedicalisation. Finally, we consider opportunities for an Indigenous understanding of health to contribute to the demedicalising aspirations of intersex advocates and researchers.

An experimental philosophical bioethical study of how human rights are applied to clitorectomy on infants identified as female and as intersex

Clitorectomies performed on the genitals of infants identified as female and as intersex have been described both as similar procedures and as different procedures. The former types of surgery have been recognised more consistently as human rights abuses than the latter in recent decades. We tested social psychological explanations of why human rights are differently recognised when infants are described as 'intersex' or 'female'; 122 laypeople in the UK read one of two near-identical descriptions of clitorectomies performed on intersex or female infants and reported their agreement with 22 items about the human rights of such infants. Clitorectomies were perceived as violating human rights more by women than by men, and more so when infants were described as female than intersex. Endorsement of human rights was better predicted by several psychological variables when infants were described as female than as intersex. Less politically conservative participants, as assessed by a Right-Wing Authoritarianism measure, and participants who trusted medical authority more recognised human rights violations of female infants more than intersex infants. Results are discussed with respect to human rights efforts to protect infants from medically non-necessary genital surgery on the basis of membership in identity categories or possession of sex characteristics.

Towards an agency-based model of intersex, variations of sex characteristics (VSC) and DSD/dsd health

Agency-based approaches to the health of intersex people and those with DSD focus on bodily autonomy and the cessation of normalising medical interventions until an under-age person can exercise fully informed choice regarding treatment. Discussions regarding intersex agency and health care can be inspired by the social model of health that emerged from disability theory. However, a purely social model is insufficient to address the harms that has been caused by DSD medical interventions, and the healthcare needs that some intersex people have. Drawing on original empirical research conducted in Italy, Switzerland and the UK, this article explores agency-based approaches to intersex and DSD, incorporating the social model's critique of the pathologisation of bodily diversities, whilst supporting the provision of effective healthcare where needed. The article addresses healthcare deficits and their cultural underpinnings. It identifies key impediments to intersex agency, including body normativity and sex and gender binarism. While there has been slight movement towards an agency-based approach to intersex in some national medical settings in the last ten years, there is still a need for change to the conceptualisation of intersex/DSD and subsequent revisions to healthcare provision.

New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study

A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002-2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8-12.1). Median follow-up (FU) was 3.9 years (1.3-6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.

The need for a unified ethical stance on child genital cutting

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.

Male or female genital cutting: why 'health benefits' are morally irrelevant

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.

Current critiques of the WHO policy on female genital mutilation

In recent years, the dominant Western discourse on "female genital mutilation" (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called "the standard tale" of FGM (also termed "female genital cutting" [FGC]). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO's terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable.