A framework for the ethically justified clinical management of intersex conditions

Intersexual Births: The Epistemology of Sex and Ethics of Sex Assignment

This article aims to analyse a possible manner of approaching the birth of intersexual children. We start out by summing up what intersexuality is and how it is faced in the dominant clinical practice (the "treatment paradigm"). We then argue against this paradigm, in favour of a postponement of genital surgery. In the second part of this paper, we take into consideration the general question of whether only two existing sexes are to be recognized, arguing in favour of an expansion of sex categories. In the third part, we illustrate the reasons supporting provisional sex attribution: the child's best interest and respect for their developing moral autonomy. This position aims to increase the child's well-being and self-determination, limiting parents' freedom to take decisions on behalf of others, in particular, those decisions concerning basic aspects of their children's personal identity.

Guidelines for evaluating and managing children born with disorders of sexual development

Children born with disorders of sexual differentiation (DSD) pose numerous challenges for the parents, family, and treating physicians. The pediatrician is usually the first medical contact for newborns with DSD or for toddlers and children who present with DSD at a later time. Several years ago, we formed a Gender Medicine Team (GMT) at Baylor College of Medicine and Texas Children's Hospital (TCH) to explore and evaluate the most appropriate management strategies, which had long been a matter of concern and contention. Subsequently, the GMT, composed of experts in the fields of endocrinology, ethics, genetics, gynecology, psychology, pediatric surgery, and urology, formed a Task Force to evaluate the information available from our own experiences and from reviews of the literature. Utilizing the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system to assess the evidence and recommendations, the Task Force developed a consensus statement for clinical management of DSD and for making appropriate sex assignments.

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.

A 7-YEAR EXPERIENCE OF GENETIC MALES WITH SEVERE PHALLIC INADEQUACY ASSIGNED FEMALE

PURPOSE

We examine the hypotheses underlying the clinical decision to assign female gender at birth in male neonates with severe phallic inadequacy.

MATERIALS AND METHODS

A total of 18 genetic males with severe phallic inadequacy were assessed longitudinally for physical, social, psychological and sexual identity development. Diagnoses included cloacal (11) and classic (1) exstrophy, partial androgen resistance (3), mixed gonadal dysgenesis (2) and penile agenesis (1). Neonatal sex assignment was female in 15 and male in 3 patients.

RESULTS

All patients demonstrated marked male typical behaviors and interests. Of the 15 female assigned patients 1 died, 1 refused to declare sexual identity or orientation, 1 converted to male before initial evaluation, 1 was reassigned male by the parents and 5 others declared male sexual identity. Thus, of 17 living patients 10 live as males and 6 as females. Of patients 17 years or older only those living as male lived independently. The 4 oldest patients living as male but only 1 patient living as female would discuss sexual orientation-all 5 declared orientation toward females, and 3 of these 4 males had girlfriends or were married. The sexually undeclared patient lived in a residential treatment center because of major behavioral difficulties since age 15. Only patients living as male had dated.

CONCLUSIONS

This longitudinal study implies that males with severe phallic inadequacy reared male and those reared female but converting to male can have functional psychosocial developmental trajectories. Those reared female have a realistic likelihood of recognizing male sexual identity and converting to male. Those not converting to male appear to have less successful psychosocial developmental trajectories.

Psychosexual development in genetic males assigned female: the cloacal exstrophy experience

Genetic males who have cloacal exstrophy, a rare, severe pelvic field defect that leads to aphallia, traditionally have been socially, legally, and surgically sex-assigned female at birth and reared female, despite a male karyotype and a typical male prenatal hormonal milieu. Psychosexual development in such children previously has been unknown. Studies of 29 children revealed that despite the absence of the typical postnatal and pubertal androgen surges and the presence of female genitalia, all female-assigned subjects displayed a marked male-typical shift in psychosocial and psychosexual development. Nearly half of them have declared themselves male. Psychosexual development, including gender identity, in genetic and hormonal male neonates seems to be influenced heavily by prenatal androgen exposure. The clinical practice of surgical sex assignment at birth requires re-evaluation.