Ethics of Gender Assignment

Classification: News

These ethics of gender assignment for children born with intersex conditions were presented by William Reiner, M.D. at the Duckett Memorial Lecture, University of Michigan, July 21, 2000. Dr. Reiner is a physician in the Division of Child Psychiatry and in the Division of Pediatric Urology at Johns Hopkins University. The title of Dr. Reiner’s talk was “How I learned to Stop Worrying and Love the Unknown.”

New Precepts

  1. Sex assignment is never emergent or urgent.
  2. We cannot manufacture unambiguous data to replace real ambiguity.
  3. We are not medical experts if we do not know the outcome and the good of our proposed medical procedures.
  4. The children know their gender identity.
  5. The children’s intuition is the data.
  6. Thus, we must espouse what the child tells us is his gender—medical procedures must come from those data, not to those data.
  7. Gender will be assigned at or near birth—legally and socially.
  8. We cannot know if our assignment will be correct, at the time of the child’s birth.
  9. Therefore, we must choose what appears to be the likeliest gender identity.
  10. If the children later tell us we are wrong, we shall then adjust accordingly.
  11. We must be flexible and patient, and teach the parents flexibility and patience.

Practicalities

  1. The children cannot tell us until old enough to weild and manipulate vocabulary within syntax—about ages 6 to 8 years.
  2. Yet gender will be assigned at or near birth—and we cannot know if our assignment will be correct.

The Ethics of Gender Assignment

  1. We must be flexible.
  2. We must be observant.
  3. We must listen.

Surgical Realities

  1. The children will want surgical (re)construction.
  2. Surgery is never emergent or urgent.
  3. We must not remove what a child may later want.
  4. Puberty can be delayed if necessary (eg, 46,XX CAH Prader 5 children).

Surgical Principles

  1. Delay surgery until the child asks for it—based on gender identity.
  2. Do not push surgery—for example:
    • Clitoral hypertrophy may not be undesired.
    • A 46,XX CAH Prader 5 child may not want the ovaries—but wait until she tells you.
    • …and so on.