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.
|
