Key points of comparison
| | Concealment Centered Model
|
What is intersex? | Intersex
is an anatomical variation from the "standard" male and female types;
just as skin and hair color varies along a wide spectrum, so does
sexual and reproductive anatomy. Intersex is neither a medical nor a
social pathology. | Intersex is an
anatomical abnormality which is highly likely to lead to great distress
in the family and great distress for the person with an intersex
condition. Intersex is pathological and requires medical attention. |
Is gender determined by nature or nurture? | Both,
surely, but that isn't the point! The point is that intersexed people
ought to be treated with the same basic ethical principles as everyone
else - respect for their autonomy and self-determination, truth about
their bodies and their lives, and freedom from discrimination.
Physicians, researchers, and gender theorists should stop using
intersex in "nature/nurture" experiments or debates. | Nurture.
Virtually any child can be made into a "boy" or a "girl" if you just
make the genitals look convincing. It doesn't matter what the genes,
brain, pre-natal life are/were like. |
| Are intersexed genitals a medical problem? | No.
Intersexed genitals are not a medical problem. They may signal an
underlying metabolic concern, but they themselves are not diseased;
they just look different. Metabolic concerns should be treated
medically, but intersexed genitals are not in need of medical
treatment. There is no evidence for the concealment paradigm, and there
is evidence to the contrary. | Yes. Untreated intersex is highly
likely to result in depression, suicide, and possibly "homosexual"
orientation. Intersexed genitals must be normalized to whatever extent
possible if these problems are to be avoided. |
| What should be the medical response? | The
whole family should receive psychological support (including referrals
to peer support groups) and as much information as they can handle.
True medical problems (like urinary infections and metabolic disorders)
should be treated medically, but all non-essential treatments should
wait until the person with an intersex condition can consent to them. | The
correct treatment for intersex is to "normalize" the abnormal genitals
using cosmetic surgical technologies, cosmetic hormone technologies,
and so on. Doing so will eliminate the potential for parents'
psychological distress. |
| When should treatments designed to make a child's genitals look "normal" be done? | Only
if and when the intersexed person requests them, and then only after
she or he has been fully informed of the risks and likely outcomes.
These surgeries carry substantial risk to life, fertility, continence,
and sensation. People with intersex conditions should be able to talk
to others who have had the treatments to get their views. | As soon as possible because intersex is a psychosocial emergency. The longer you wait, the greater the trauma. |
| What is motivating this treatment protocol? | The
belief that the person with an intersex condition has the right to
self-determination where his or her body is concerned. Doing
"normalizing" surgeries early without the individual's consent
interferes with that right; many surgeries and hormone treatments are
not reversible. The risks from are substantial and should only be taken
if the patient has consented.
| The belief that our society
can't handle genital ambiguity or non-standard sexual variation. If we
don't fix the genitals, the child with an intersex condition will be
ostracized, ridiculed, and rejected, even by his or her own parents. |
| Should the parents' distress at their child's condition be treated with surgery on the child? | Psychological
distress is a legitimate concern and should be addressed by properly
trained professionals. However, parental distress is not a sufficient
reason to risk a child's life, fertility, continence, and sensation. | Yes,
absolutely. Parents can and should consent to "normalizing" surgery so
that they can fully accept and bond with their child. |
Key points of comparison
| PATIENT--CENTERED MODEL
| CONCEALMENT--CENTERED MODEL
|
| How do you decide what gender to assign to a newborn with an intersex condition? | The
parents and extended family in consultation with the doctors. This
approach does not advocate selecting a third or ambiguous gender. The
child is assigned a female or male gender but only after tests
(hormonal, genetic, diagnostic) have been done, parents have had a
chance to talk with other parents and family members of children with
intersex conditions, and the entire family has been offered peer
support. We advocate assigning a male or female gender because intersex
is not, and will never be, a discreet biological category any more than
male or female is, and because assigning an "intersexed" gender would
unnecessarily traumatize the child. The doctors and parents recognize,
however, that gender assignment of infants with intersex conditions as
male or female, as with assignment of any infant, is preliminary. Any
child may decide later in life to change their gender assignment; but
children with intersex conditions have significantly higher rates of
gender transition than the general population, with or without
treatment. That is a crucial reason why medically unnecessary surgeries
should not be done without the patient's consent; the child with an
intersex condition may later want genitals (either the ones they were
born with or surgically constructed anatomy) different than what the
doctors would have chosen. Surgically constructed genitals are
extremely difficult if not impossible to "undo," and children altered
at birth or in infancy are largely stuck with what doctors give them. | The
doctors decide based on medical tests. If the child has a Y chromosome
and an adequate (or "reconstructable") penis penis in the eyes of the
doctors, the child will be assigned a male gender. If the child has
a Y chromosome and an adequate penis (or "reconstructable") penis, the
child will be assigned a male gender. (Newborns must have penises of 1
inch or larger if they are to be assigned the male gender.) If the
child has no Y chromosome, it will be assigned the female gender. The
genitals will be surgically altered to look what the doctors think
female genitals look like. This will include clitoral reduction
surgeries and construction of a "vagina" (a hole).
|
| Who should counsel the parents when an intersex child is born? | Intersex
is a community and social concern requiring understanding and support.
Counseling should begin as soon as the possibility of intersex arises
and/or as soon as the family needs it. Professional counselors trained
in sex and gender issues, family dynamics, and unexpected birth
outcomes should be present. Families should also be actively connected
with peer support. | Intersex is a psychosocial emergency that
can be alleviated by quick sex assignment and surgery to reinforce the
assignment. Professional counseling is suggested but typically not
provided. Peer counseling is typically not suggested or provided. |
| What should the intersexed person be told when she or he is old enough to understand? | Everything
known. The person with an intersex condition and parents have the right
and responsibility to know as much about intersex conditions as their
doctors do. Secrecy and lack of information lead to shame, trauma, and
medical procedures that may be dangerous to the patient's health.
Conversely, some people harmed by secrecy and shame may avoid future
health care. For example, women with AIS may avoid medical care
including needed hormone replacement therapy. | Very little,
because telling all we know will just lead to gender confusion that all
these surgeries were meant to avoid. Withhold information and records
if necessary; use euphemisms (like "we removed your twisted ovaries"
instead of "we removed your testes" when speaking to a woman with AIS). |
| What's wrong with the opposing paradigm? | The
autonomy and right to self determination of the person with an intersex
condition is violated by the surgery-centered model. In the concealment
model, surgeries are done without truly obtaining consent; parents are
often not told the failure rate of, lack of evidentiary support for,
and alternatives to surgery. Social distress is a reason to change
society, not the bodies of children. | Parents and peers might
be uncomfortable with a child with ambiguous genitalia. Social
institutions and settings like locker rooms, public restrooms, daycare
centers, and schools will be brutal environments for an "abnormal"
child. The person with an intersex condition might later wish that her
or his parents had chosen to have her or his genitals "normalized". |
| What is the ideal future of intersex? | Social acceptance of human diversity and an end to the idea that difference equals disease. | Elimination via improved scientific and medical technologies. |
| Who are the proponents of each paradigm? | Intersex
activists and their supporters, ethicists, some legal scholars, medical
historians, and a growing number of clinicians. | John Money
and his followers, most pediatric urologists and pediatric
endocrinologists, and many gynecologists and other health care
practitioners. |