A shift away from surgery on babies of indeterminate gender.

Health and medicine explained.
June 8 2004 7:00 PM

The Cutting Edge

Why some doctors are moving away from performing surgery on babies of indeterminate gender.

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The sort of interventionist strategy encouraged by Money creates its own deformities, says Cheryl Chase, founder of the Intersex Society of North America. (For Chase's story, click here.) It might seem that designating gender for ambiguous-looking infants is a mistake altogether. Yet even the most vociferous antisurgery activists say gender labels are necessary to exist in our culture. They argue, however, that doctors should simply refrain from medically unnecessary surgeries that make those labels permanent. The important thing, Chase says, is to allow children with ambiguous genitalia to come to terms with their identities and to provide them with counseling as they do so.

But many physicians find this thinking unethical. Urologists argue that genital surgeries have the best outcomes if performed early in life. Other doctors insist that most reassigned children go about life quietly and—they presume—contentedly. Between neighborhood gossip and the casual body exposure typical among small children, these doctors point out, a child who looks unidentifiably male or female will quickly become known to his peers. Leaving such children unaltered, writes Columbia urologist Kenneth Glassberg in the Journal of Urology, cruelly exposes them to "be considered freaks by their classmates."

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Meanwhile, even those who advocate avoiding early surgery concede it's not always clear how to answer a small child demanding change to his or her external gender. (As with all aspects of the issue, no statistics exist to show how often these requests take place. The state-of-the-art team at Texas Children's, for example, has only been in operation for three years—so its patients are barely old enough to talk.) But there are some clues: At age 3, almost all children identify themselves as a particular gender, announcing, if asked, "I'm a boy" or, "I'm a girl." They may also have wishes about their external genitalia—a 3-year-old, say, might want a penis, even if she doesn't fully understand what that is—but a child of 3 or 4 can't really understand the implications of surgery. At age 13 or 14, according to conventional child-development theory, children are mature enough to start making serious decisions—such as choosing surgery with a full understanding of the consequences.

With these guidelines in mind, the Texas team tracks its patients carefully, offering families psychological counseling, peer support, and medical monitoring. The goal is to help the children themselves to decide finally how they want their bodies to look. This team is one example that, across the country, the reflexive use of gender reassignment surgery is waning. But not quickly enough. Unless they're born in Texas, the great majority of ambiguous-looking babies will still be "normalized" with radical, irrevocable surgery in their first year of life.

But the anecdotal and scientific evidence is making it increasingly clear that this approach, which once seemed obvious, is not in every child's best interest. Doctors acknowledge that it is often medically unnecessary; many former patients argue compellingly that early surgery can be physically and psychically destructive. In the chaotic first months after a physically anomalous birth, then, it's the parents who must guess how to best ensure a happy future for a healthy but different-looking child. That child will later have more options if his or her parents decide, first, to do no potential harm.

Claudia Kolker is a writer based in Houston.