2000 John W. Duckett Lectureship Invitation
2000 John W. Duckett, Jr., M.D. Pediatric Urology Lectureship
Friday, July 21st, 2000
8:30 a.m.-12:00 p.m.
Dow Auditorium, Towsley Center
University of Michigan Health System
Ann Arbor, Michigan
Each year, the University of Michigan’s Pediatric Urology Department hosts a lectureship in honor of the late John Duckett (a prominent surgeon well known for his hypospadias surgeries). In 2000, the lectures focused on a single topic: the increasingly evident paradigm shift in medical thinking about intersex.
Douglas A. Canning, M.D.
Associate Professor, Urology, Children’s Hospital of Philadelphia
University of Pennsylvania School of Medicine
Canning discussed a patient who was one of non-identical twins born in 1993, both with cloacal exstrophy. One of the children died during the first year of life, but with surgery the other child lived, and was raised as a girl because of the small phallus. Earlier this year, at age 8, thischild transitioned to live as a boy. “Our thinking has begun to change in the past six months,” said Canning, and praised ISNA’s approach as enlightened.
The History and Current State of Intersex Surgery
Anthony J. Casale, M.D.
Associate Professor, Department of Urology, Indiana University School of Medicine
Casale noted that surgeons have tended to emphasize technique over indications or philosophy, and started out his talk with a discussion of attitudes toward intersex in the Greek and Roman classical world, then jumping to rumours about Pope Joan (was she an intersexed woman?), and showing a photograph of the chair which was used to confirm the presence of testicles in candidates for the office of Pope.
In regard to clitoral surgery, Casale touched upon Hugh Hampton Young, Lawson Wilkins, the 1966 paper by Gross, Randolph, and Crigler (Clitorectomy for sexual abnormalities: Indications and technique. Surgery, 59 (2), 300-308), which emphasized comlete clitoral extirpation. Though John Lattimer is often thought to have been the first surgeon to attempt to preserve parts of the clitoris, Casale noted that Ombredene in France was performing recessions in 1939. Mollard introduced clitoroplasty in1981, but the neurovascular bundle was delicate, and easily injured during dissection. Kogan’s 1983 technique attempts to work around this problem.
Unlike the clitoris and labia, where the surgeon’s attention is purely cosmetic,the urogenital sinus can present an actual medical problem. Casale discussed UG sinus surgeries developed in the second half of the 19th century in Europe,then Neugebauer 1908. These techniques were brought to the U.S. by Young. Lattimer introduced the posterior flap vaginoplasty in 1958, Hendren thepull-through for high UG sinus in 1969. Hendren’s dissection was difficult, and fistulae often resulted. Passerini worked to augment the vagina (1989), and Pena introduced the total UG mobilization (1997) for cloacal and UG sinus repairs.
Techniques for labial reconstruction were introduced by Marburger and by Allen in 1975.
Casale said that current surgical techniques have outstanding surgical results,but functional results are unknown, and patient satisfaction is questionable, though patients “appear to do well.”
Intersex Dilemma: Is There A Paradigm Shift?
Steven J. Skoog, M.D.
Professor of Urology, Oregon Health Science Center
There is a controversy, Skoog acknowledged. Why? Read Colapinto’s 1997 Rolling Stone article for revelation of the outcome of the John/Joan case, and insight into what really happened. We must listen! Skoog showed a picture of ISNA’s web page, and asked how many in the audience had visited the site. Only two or three raised their hands. Skoog recommendedit highly for news and resources, and noted that he had used ISNA’s bibliographyfor many of the citations in his own presentation that day, and that he refersparents to ISNA’s web site.
Skoog accurately recounted ISNA’s criticisms:
- Intersex is a variation, not a disease, so we should not be “normalizing” these children.
- Surgical results, risks, and complications are poorly documented, resulting in unknown outcomes.
- Quality of life studies are lacking. (History is relevant; cf. Money)
- Gender assignment is preliminary, so no surgery should be done w/o child’s consent.
Skoog noted that the Constitutional Court of Colombia had recently intervened to prohibit genital surgery on two intersex children.
What are the controversies? Skoog reviewed phenotypic development, noting that what happens prenatally is clear, but that postnatal issues are controversial. In addition, the increased acceptance of homosexuality in today’s society is a factor that will affect treatment.
Psychosexual differentiation is controversial. “I’m less comfortable with [our knowledge of] this. As surgeons, these factors are more important for patient happiness [than those factors we understand better].”
“Money, in 1955, formed authoritative principles which have guided my practice. I thought Money understood. I can think of no other instance [besides intersex] where we would hide information in this way. This was Money’s principle. There has been intellectual dishonesty on our part. I bit into this [gender neutrality of infants], but I saw it wasn’t in my heart, when the patients came back.”
“A huge problem is the parents’ relationship with the child. We tell them to deny the child’s need to act male. We are seeing patients treated by Money’s paradigm, who are having all the problems he described.”
Skoog praised the Dreger model (psychology-centered rather than surgery-centered), but bemoaned the fact that “we can’t find psychologists!” Skoog noted that the phrase “until further data become available, caution should be exercised when a recommendation is made that the sex of rearing should differ from the chromosomal sex” (in the AAP’s new guidelines, published in Pediatrics, July 2000) represents a “flinch” on the part of the medical establishment. “I personally will no longer make children with micropenis into females.”
Is there a paradigm shift? Yes, Skoog answered. We need to help the advocacy groups destigmatize intersexuality as part of our patient care; we need to educate parents and society. We need to provide psychological support on a lifelong basis. We need to listen to the opinions of all our patients. The degree of androgenization is a major factor in sex of rearing. The criticisms of ISNA are valid; we must assess results by quality of life, not by measuring stenosis. At the same time, it’s important to note that the present paradigm has not yet been proven wrong.
Philosophy & Ethics of Gender Identity
William G. Reiner, M.D.
Assistant Professor, Department of Child & Adolescent Psychiatry
Johns Hopkins Hospital
Reiner presented his Ethical Precepts of Gender Assignment.