The story has all the makings of a gynecological horror flick: "Cornell Surgeon Used Vibrator To Stimulate 6-Year-Olds," gasped the headline in Jezebel. Dan Savage declared himself so angry that "I hardly know where to start." (On our own XX Factor blog, my colleague Rachael Larimore called it "appalling.") The villain in this medical horror story is one aptly named Dr. Dix Poppas, a pediatric urologist at Cornell University who specializes in genital reconstruction. Outrage was so universal that a new Facebook page called "End Genital Mutilation at Cornell University" is racking up thousands of members a day, and Poppas has begun receiving death threats.
Is it true? Is there some rogue doctor surgically slicing the clitorises of little girls and then testing them with vibrators? Not exactly. The scandal concerns a medical paper Poppas and two colleagues wrote three years ago in the Journal of Urology describing a method Poppas was using to test clitoral sensitivity after surgery. (A paper discussing that research is here.) Two bioethicists, Alice Dreger and Ellen Feder, dredged up the paper last week and published an article in Bioethics Forum comparing Poppas' work to the infamous Tuskegee Syphilis Project and saying a quorum of their colleagues had declared it "outrageous." Dreger and Feder also raised many valid ethical questions about Poppas' research, but when the words "clitoris," "6-year-old," and "vibrator" appear in the same essay, the blogosphere translates that into "Pervert Surgeon Wields Knife, Seeks Thrills."
The patients in question are girls with a condition known as CAH, or congenital adrenal hyperplasia, which affects about one in 5,000 girls. Genetically, they are girls, but a hormone imbalance causes their clitoris to be enlarged, sometimes only slightly more than average, and sometimes so much that at birth they are mistaken for boys—particularly if they have a fused labia that looks like a scrotum. For many years the standard treatment for this has been what the outraged masses are now calling "genital mutilation" and what doctors call clitoroplasty, or cosmetic reduction of the size of the clitoris, usually done on infants before they turn 1. Forty years ago, doctors would opt for a clitoridectomy, or the complete removal of the organ. Now, Poppas and others opt for "nerve sparing" surgery to try to preserve the sensations.
So where does the vibrator come in? In the last few years, many critics—Dreger, Feder, and Dan Savage among them—have begun to question whether the surgery is necessary at all, nerve sparing or otherwise. Nerve sparing does not always work. As Dreger points out, Poppas' surgery preserves the glans (tip) of the clitoris but cuts out the shaft, although many women masturbate using the shaft. But their larger objection is that the surgery is purely cosmetic and thus unnecessary. "If he really cared about maximizing these girls' function," writes Dreger on her blog, "he would not be doing surgery on their healthy clitorises."
Poppas devised a crude test to answer these critics and measure the effectiveness of his nerve-sparing surgery. Poppas used a machine called a biothesiometer, used to test vibrations in human subjects. Health writer Lindsay Beyerstein explains his method: "With a parent and a female nurse practitioner looking on, the doctor would measure the patient's sensitivity threshold by dialing up the stimulus until she could feel it and rate its intensity. Poppas didn't stimulate the patients to orgasm, nor attempt to induce sexual pleasure or arousal." He also used a Q-tip to test sensitivity in the inner thigh and vagina.
This set-up was far from ideal. Poppas did not go through the standard channels of approval for the experiment, even though he was performing these tests on girls as young as 6. He measured capillary refills of the clitoris and response to vibrations. But as Eric Vilain, a professor of human genetics at UCLA, points out, "Is there any evidence that those measures performed in children correlate in any way with later sexual function?" The endpoint is not sensation in a 6-year-old, but quality of an adult sex life. In Poppas' measurements, for example, sensation on the inner thigh measured far higher on some tests than sensation on the clitoris, maybe because 6-year-olds are more prone to tickling.
The patients Poppas tested could never benefit from the test. If Poppas found no sensation, he would have no way to reverse the operation. In the small world of children born with abnormal genitals, there is a long history of horrendous postoperative testing, both psychological and physiological. (See the awful stories chronicled by John Colapinto in As Nature Made Him.) Poppas, who did not return calls, likely knew that he would have a hard time getting approval for his experiment. But that does not make him a child molester. He was trying to answer a legitimate scientific question about a set of his patients.
To his critics, however, these details don't matter. Savage calls this a conspiracy of "out and out homophobia." He claims the medical establishment pushes these operations because girls with bigger clitorises are more likely to be lesbian. This claim is a stretch; girls with CAH are only slightly more likely to be lesbians or tomboyish when they are young. The vast majority are heterosexual and comfortable as girls. Gender norms have shifted pretty drastically in the 40 years that this operation has been performed, and still more than 95 percent of parents choose it for their children. Why? Because much as Savage might like it to be, the world is not yet a place where most little girls can have a clitoris that looks like a penis and feel entirely at ease. And few parents would want to use their daughter to test that proposition.