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Peter Lee, M.D.
Professor of Pediatrics, University of Pittsburgh; Immediate Past President, Lawson Wilkins Pediatric Endocrine Society
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YES
First, it would be important for me to make a distinction between cosmetic and corrective surgery. Cosmetic surgery implies that the surgery is done just so that the organ has a more pleasing appearance.
For example, mammoplasty to change the size of a woman’s breasts or make them symmetrical or the same shape is cosmetic surgery. But mammoplasty for a young man who has had persistent gynecomastia is generally not considered cosmetic surgery, but rather corrective surgery. Most males with gynecomastia choose such surgery when given a choice. But the infant cannot yet make the choice. In fact, in many cases evaluated for ambiguous genitalia, surgery should not be considered-in situations in which there is mild clitoro-megaly, for example.
The situations in which surgery should be considered are those cases with clearly ambiguous genitalia. Parents should be told all that is understood about the underlying cause of the problem. The parents should know what the treatment options are, including surgery if appropriate.
The discussions with the parents need to include the fact that they are being asked to make decisions for their child’s future without benefit of any input from their child.
In cases of ambiguous genitalia, a decision needs to be made concerning what has been termed “sex of rearing” or “gender assignment.” Only the most extreme would advocate raising a child as a third sex. But in situations in which the genitalia are severely ambiguous, the option for corrective surgery should be presented.
My experience suggests that many, if not most, of the people who had surgery as infants are pleased with the choice.
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Philip A. Gruppuso, M.D.
Pediatric endocrinologist, Brown University, Providence, R.I. |
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NO
Surgery is indicated for these children to prevent medical complications, such as urinary-tract infections. But I no longer recommend cosmetic surgery during infancy for the purpose of giving these children’s genitals a more normal appearance.
While such surgery may satisfy parents’ concerns about their child’s social development long-term, the outcome may be much poorer than had previously been thought. Negative outcomes resulting from standard practices may not receive the same attention as positive outcomes. Over the last several years, patient support and advocacy groups have decried cosmetic genital surgery, because of poor results.
Predicting the future gender identity of an infant with ambiguous genitalia is uncertain at best. I have been involved in a case in which the patient reversed the gender “assigned” at birth once he reached adolescence. Surgery he had as a newborn might not have been performed had male gender been assigned.
That a child’s social development will suffer because he or she is deprived of cosmetic genital surgery is an untested hypothesis. Equal consideration should be given to the impact of painful surgery, especially if it is inappropriate to the patient’s ultimate gender, or if it results in impaired sexual function.
This area has been overly influenced by anecdotal and, in some cases, inaccurate clinical data. The concept that unambiguous rearing of an infant guarantees gender identity has been called into question. Therefore, the role of cosmetic surgery in unambiguous rearing should also be questioned. I advocate a moratorium on such surgery until clinical studies are performed.
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