Do No Harm: Stop Infant Genital Surgery

Being a little let's call it resourceful: this week's post is an excerpt from my paper. If you're interested in the psychology of early genital surgery or how male circumcision might weigh in on this argument, here you are: 

Often, the first response to a baby being born is two questions: 1) is it healthy? and 2) is it a boy or a girl? For perhaps 1.7% of newborns, the answer to the latter is not obvious and causes significant distress for the parents. Before a now-controversial publication by John Money in 1955, society was unsure of what to do in these situations – if anything even needed to be done. His essay, “Hermaphroditism: Recommendations concerning assignment of sex, change of sex, and psychological management” established the standard practices by which many physicians still operate today, claiming that early sex assignment – often achieved by genital correction surgery – is the key to maximizing the likelihood of a successful gender identity formation. Just recently, however, as the children directly affected by Money’s encouragement to perform genital surgery have become adults, are we beginning to question this suggested practice.

In her essay “Should There Only Be Two Sexes?” Anne Fausto-Sterling, a professor of Biology and Gender Studies at Brown University, questions the practice of genital surgery asserted by Money: “However well-intentioned, the methods for managing intersexuality, so entrenched since the 1950’s, have done serious harm” (Fausto-Sterling, 2000, p. 125). Indeed, she argues for a redefinition of our binary sexed world and offers new guidelines on how doctors should handle intersexuality. Following careful consideration of the competing claims of Money and Fausto-Sterling and the examination of psychological evidence provided by Slijper’s et al. (1998) study, I argue that early genital surgery should not be performed in cases of neonate genital ambiguity.

Fausto-Sterling’s claim that “medicine’s focus on creating the proper genitals, meant to prevent psychological suffering, clearly contributes to it” was not enough to satisfy me (Fausto-Sterling, 2000, p.128). Without any specific evidence of the psychological studies to which she refers, I could not fully accept her argument, so I located a research study that she references by Slijper et al. in 1998. It describes the investigation of 59 children with a physical intersex condition over a ten-year period. A team of healthcare professionals, spanning several disciplines, at Sophia’s Children Hospital in The Netherlands sought to prevent the development of cross-gender identification in this sample of intersex children. To this aim, newborns were each assigned a sex and were surgically modified to fit that sex within the first year of life. Following surgery, the children and their parents participated in psychotherapy for the duration of the study in accordance with John Money’s guidelines for treating intersex patients.

The researchers investigated the rates of the development of general psychopathology, gender identity disorder, and gender behavior deviance. Not surprisingly, the children seemed to cope more successfully when they displayed a flexible and resilient personality. Despite this and Money’s supposition that early genital surgery increases life satisfaction, 39% of the children developed severe general psychopathology including depressive neurosis and anxiety as determined by diagnostic criteria outlined in the DSM-IV. Additionally, 13% of the girls exhibited gender identity disorder (GID). While these results indicate that early counseling and parental support seem to have some preventive effect, psychopathology and GID still developed at higher-than-average rates in the children, which should implicate some doubt for the efficacy of surgical treatment of intersex children.

 “We protest the practice of genital mutilation in other cultures, but tolerate them at home” (Fausto-Sterling, 2000, p. 125). This bold comment from Fausto-Sterling prompted me to also think about the practice of male circumcision in light of the present argument. Canadian nurse and social advocate Kira Antinuk writes about what she calls forced nontherapeutic genital cutting in light of both intersex genital surgery and male circumcision, drawing riveting parallels between the two (Antinuk, 2013). She argues, like Fausto-Sterling does for infant genital surgery, that the practice of circumcision serves no physical or medical benefit and that performing such a procedure is in fact genital mutilation. Additionally, Antinuk posits that children should at the very least be granted the opportunity to choose to be circumcised, just as intersex children should have the opportunity to choose their gender upon reaching an appropriate age.

Can it be argued that early genital surgery in the case of intersex infants is forced nontherapeutic genital cutting? I think so. Like circumcision, the pretense of doing what is best for the child or conforming to social norms clouds our judgment and prevents us from seeing it that way. If these procedures were deemed medically necessary to save the child’s life or improve his/her physical well-being, then obviously medical steps should be taken to reach those ends. But that is not the case we are describing here. Still it seems that genital mutilation, which Western society finds deplorable, is occurring here at home more than we would like to know.  

Given this, it is imperative that we better understand the intricate interplay among mainstream Western society’s established gender norms, medicine’s role in condoning early genital surgery, and parents’ wish both to accept children as they are and to shape them in accordance with societal norms. The most conclusive way to do this is to empirically study these individuals; however, at present there exists no systematic comparison of long-term psychological outcomes between intersex individuals who did have early genital surgery and those who did not, making it difficult to reach a verdict on the efficacy of early genital surgery.

While there is no denying that the practice of genital surgery confirms the binary sex system we currently live in, questions about whether to enforce the binary at the expense of newborns by performing unnecessary surgeries on them may be less clear. The real shame in all this is that genital surgery has not even proven effective; in addition to the problems Fausto-Sterling raises, some women who have chosen genital surgery for intersex conditions as adults found that surgery, which was supposed to fix appearance and sexual function, failed to solve either of those problems. While this may be true, it is important to realize that medical professionals do not intend to harm; indeed, they do the opposite. It is just in this case that the once-accepted practice of infant genital surgery to correct a social (not medical) problem must be reevaluated. It seems that whether early genital surgery is performed or not, intersex individuals will face major identity and psychological crises later in life. Therefore, I am inclined to say that if intersex individuals incur similar psychological damage with or without infant genital surgery, then we should avoid the removal or alteration of organs the individual might later identify with. By allowing the child to remain biologically ambiguous, you allow her to decide her gender at an appropriate age without removing the biological organs that she might one day want.