Two articles in the Archive of Pediatric and Adolescent Medicine (May 2004) examine the current protocol surrounding intersex conditions. The first harshly criticizes the current protocol that offers no support and often results in feelings of shame. The second article is a critique of the first but also recognizes the need for change.

• Health Care Professionals and Intersex Conditions
  Frader, J., Alderson, P., Asch, A., Aspinall, C., Davis, D., Dreger,
  A., Edwards, J., Feder, E. K., Frank, A., Hedley, L. A., Kittay, E.,
  Marsh, J., Miller, P. S., Mouradian, W., Nelson, H., Parens, E.
  Arch Pediatr Adolesc Med 2004 158: p. 426-428 http://archpedi.ama-assn.org/cgi/content/full/158/5/426?ct. Read the article. (PDF)
• Reality vs Recommendations in the Care of Infants With Intersex Conditions--Invited Critique
  Eugster, E. A.
  Arch Pediatr Adolesc Med 2004 158: p. 428-429 http://archpedi.ama-assn.org/cgi/content/full/158/5/428?ct Read the article. (PDF)
  

A recent paper by William G. Reiner and John P.Gearheart published 1/22/2004 in the New England Journal of Medicine follows up on boys born with cloacal exstrophy (the bladder or intestine develops outside the body and in boys often results in small, absent or deformed penis) who underwent sex reassignment surgery. While the study was small, the findings are significant in that most transitioned back to male or identify as male.

• Reiner, William G., Gearhart, John P. 2004. Discordant Sexual Identity in Some Genetic Males With Cloacal Exstrophy Assigned to Female Sex At Birth. NEJM 2004 (4) 350:333-341. (available online with permission of the lead author and the NEJM)

A truly groundbreaking study by Catherine Minto, Sarah Creighton, and colleagues was published in The Lancet, the leading medical research journal in the UK. The article examines the effects of clitoral surgery on sexual function:

• Minto, Catherine L, Lih-Mei Liao, Christopher R J Woodhouse, Phillip G Ransley, Sarah M Creighton. 2003. The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study. Lancet . 361:1252-57. Available online at:
  • Effect of Clitoral Surgery
    Registration with the Lancet is required however it is FREE and the article is also FREE

Excellent article by Sheri Berenbaum, Dept of Pyschology, Pennsylvania State University examining the treatment protocols for intersex children, and the lack of adequate follow-up studies:

• Berenbaum, Sheri A 2003 Management of Children With Intersex Conditions: Psychological and Methodological Perspectives. Growth Genetics. 19(1) 1. Available online at http://www.gghjournal.com/volume19/19_1/articles/beren.htm

Recent article by Berenbaum and Bailey that indicates most girls with CAH have female gender identity regardless of surgical status:

• Berenbaum, Sheri A., Bailey, Michael J. 2003, Effects on Gender Identity of Prenatal Androgens and Genital Appearance: Evidence from Girls with Congenital Adrenal Hyperplasia. Journal of Clinical Endocrinology & Metabolism. 88(3):1102-1106. Web access is pay per article from http://jcem.endojournals.org/cgi/content/full/88/3/1102

A commentary about the medical treatment of intersex:

• Blizzard, Robert M. 2002. Intersex Issues: A Series of Continuuing Conundrums. Pediatrics 1103 (3):616-21. A follow-up commentary is published in Growth Genetics & Hormones, Root. 2003. Commentary. 19(1):6-7. Available at: http://www.gghjournal.com/volume19/19_1/articles/commentaryintersex.htm
  • Note from Bodies: Dr. Blizzard's commentary on his commentary is of special note and interest)

Two interesting studies from Claude Migeon regarding 46, XY Intersex Individuals:

• Migeon, Claude. 2002. 46,XY Intersex Individuals: Phenotypic and Etiologic Classification, Knowledge of Condition, and Satisfaction with Knowledge in Adulthood. Pediatrics 110 (3):e32 (8 pages). Available from http://www.pediatrics.org/cgi/content/full/110/3/e32.
• Migeon, Claude 2002. Ambiguous Genitalia With Perineoscrotal Hypospadias in 46,XY Individuals: Long-Term Medical, Surgical, and Psychosexual Outcome. Pediatrics 110 (3):e31 (10 pages). Available from http://www.pediatrics.org/cgi/content/full/110/3/e31.

Research as recent as 2000 shows the structure of the clitoris remains largely unknown:

• Entrez-PubMed - Anatomical relationship between urethra and clitoris (J Urol 1998 Jun;159(6):1892-7)
• Entrez-PubMed - The suspensory ligament of the clitoris (Clin Anat 2000;13(6):397-403)

An article from the Journal of the Royal Society of Medicine by Sarah Creighton (MD MRCOG Department of Obstetrics and Gynaecology, University College Hospital, London WC1E 6AU, UK) exploring current thought on surgery for people born with atypical genitals. She calls for a review of currently accepted protocol and suggests that clinicians need to reconsider whether these surgeries are necessary:

• Surgery for Atypical Genitalia ( R Soc Med 2001;94:218-22)

December 2001 article in the British Medical Journal calling for an end ot non-disclosure to patients and their families regarding the truth and treatment of atypical genitals and managing the conditions using a multi-disciplinary approach:

• Most vaginal surgery in childhood should be deferred {BMJ 2001;323:1264-1265 ( 1 December )}

A ground-breaking statement and offering of guidelines from the British Association of Paediatric Surgeons Working Party on the Surgical Management of Children Born with Ambiguous Genitalia calling for a review of the current practices. It also includes a comprehensive appendix of currently performed genital surgeries:

• British Association of Paediatric Surgeons Working Party on the Surgical Management of Children Born with Ambiguous Genitalia, July 2001

June 30, 2001 article in The Lancet (Lancet 30 June 2001, Melton; 357:9274) discussing current research in the treatment of people with atypical genitals. A follow-up letter to the editor by Iain Morland (Lancet 15 December 2001; 358:9298) discusses the article further. The article is free from The Lancet, but requires a simple registration for access.

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