The Ethics of Intersex Surgeries

The Ethics of Intersex Surgeries
July 11, 2023 No Comments Gender Naina Bhardwa

Focus on Hearts, Not Parts: The Ethics of Youth Intersex Surgeries

By Naina Bhardwaj

What does it mean to “do good” for a child? How much control should parents get over their children’s bodies? When is it necessary to operate on a child without their consent? These are questions raised by the issue of youth intersex surgeries, a practice done to alter the genitalia of intersex individuals. As certain intersex conditions can result in an individual’s genitalia not appearing to be either male or female, many intersex people are forced by their parents or legal guardians to undergo surgeries that change the outward appearance of their genitals. Although parents may believe they are acting in their child’s best interest by doing so, hoping to prevent bullying and isolation as their child grows older, the surgery often leaves lasting negative physical and psychological impacts on the child while infringing upon their autonomy in several ways. In my paper, I will analyze the ethicality of this practice, observing the ways in which sex is surgically assigned, the several harms caused by the procedure, and applying the ethical values of autonomy and responsibility in combination with the framework of consequentialism.

Table of Contents

Abstract

“I first heard the term intersex during first or second grade when my parents took me to a check-up. Before I heard the word intersex, I used the term “DSD,” a medical phrase meaning “disorder of sex development.” I still feel that doctors use language which makes me feel like a specimen. Today I feel my body is out of my control. [..] I wish I was fully informed.”

– Teen Vogue

These are the words of Banti, a young individual who was forced to undergo surgery at a very young age to alter their genitalia. Banti did not know about the surgery when it was occurring, did not have a say in whether or not it would occur, and had no option but to suffer the long-lasting pain of this operation that ultimately had no direct benefit to their health. Why would an individual be subjected to such a treatment without their consent? For many people, it is the result of being born intersex.

The term “intersex” is used to describe individuals who are born with sex characteristics that do not all fall within the characteristics typically associated with being “male” or “female.” Intersex people often show signs of physical traits, chromosomes, or genitalia that do not align with a particular sex from a very young age, with 1.7% of the population being born with an intersex trait (Center for American Progress 2021). Historically, society has viewed intersex individuals as people who need to be surgically “corrected” to make them fit into the sex and gender binary, and as a result of this, genital and gonadal surgeries are commonplace for these infants and young children. These surgeries seek to remove or replace genitalia to make the child appear as though they are unambiguously “male” or “female”. However, with these procedures comes the bioethical issue of informed consent. Infants and children under the age of 18 cannot legally provide informed consent for surgical procedures, nor are they given the autonomy to decide how their genitalia will be altered despite the irreversible nature of these surgeries. While many intersex individuals would prefer to autonomously choose (or decline) surgery for themselves at an older age (InterAct), they are stripped of this ability. These procedures also carry a number of safety hazards and long-term risks, thus subjecting the child to potential harms which they may not be fully informed of. This paper will address some of the necessary considerations that arise from youth intersex surgery, and analyze the ethicality of the practice using the values of autonomy, equality, and the framework of consequentialism.

Factual Background

The term “intersex” is used broadly and is not technically a medical term, which means that there are multiple different medical conditions that are said to fall under the intersex umbrella. Congenital adrenal hyperplasia (CAH) is one of the most common, affecting 1 in every 10,000-15,000 people in the United States and Europe (Cleveland Clinic 2022). It occurs when there are differing levels of androgens in the adrenal glands, which can include both an overproduction of androgens or an insufficient production. The adrenal glands, located at the top of the kidneys, are responsible for the production of androgens, which are male sex hormones including testosterone and dihydrotestosterone. In infants with XX chromosomes, overproduction of androgens often results in an enlarged clitoris and a slightly closed labia, visually similar to a scrotum; thus it is not often seen as “traditional” female genitalia. Other characteristics involve facial and body hair, a deepened voice, infertility, and irregular menstruation (Mayo Clinic). In xy-chromosome-possessing individuals, testosterone biosynthetic “defects” are another common cause of ambiguous genitalia, occurring when the enzymes necessary for producing testosterone are low-functioning or not functioning entirely, thus resulting in significantly lower androgen levels. Those affected can be born with either female genitalia or ambiguous genitalia, such as an enlarged clitoris, depending on the level of functioning of each enzyme (Taplin & Slover 2009). Yet another common condition is androgen insensitivity syndrome (AIS), in which individuals are unable to physically respond to the androgens produced by the body. In cases of complete androgen insensitivity syndrome, the external genitalia will always resemble that of a female, while the internal genitalia can consist of testes. Affected individuals do not possess a uterus and cannot menstruate (Medline Plus). These conditions are simply a few among around 30 known intersex variations, all of which create different combinations of traits in the affected individuals and can have different long-term impacts on things like fertility, growth, and hormone levels. Therefore, it is important to note that not all intersex people have the same experiences nor do they all require the same medical procedures. Further, while some intersex conditions can legitimately threaten the individual’s health, genital surgeries do not address these issues as they are mainly for the purpose of physical appearance.

Historical Background

Before discussing the first instances of intersex surgery, it is necessary to understand the societal conditions from which the desire for surgical “correction” emerged in the United States. In the late sixteenth century, society in the West was constructed around rigid gender roles, with women responsible for looking after the household and raising children while men bore the expectation to obtain an education and pursue a serious career. Yet, as the public began to shift away from conservative beliefs in the 18th century, the need for a distinguishing factor between men and women that was grounded in science and fact arose. Thus, to satisfy this need, scientists (such as German anatomist Samuel Thomas von Soemmering) began researching and publishing discoveries of clear biological and physical differences between males and females, focusing on parts of the body that could be exaggerated to further enforce gender roles. Females, for example, were described as having smaller skulls than males due to their “inferior intellectual capability,” and were drawn with an enlarged pelvis for the purpose of child-bearing– thus, one’s identity became dependent on one’s outward genitalia and anatomy, creating two distinct sexes that each possessed a different societal role (Delimata 2019). Intersex people, called “hermaphrodites” at the time, however, did not fit into either category due to their ambiguous appearance, and therefore challenged the basis on which gender roles were created. Out of a desire to protect the social order and enforce the gender binary, physicians turned to genital reconstruction surgery as a way to place intersex individuals into one specific category, either male or female, based on the genitalia they were surgically “given”– this paved the way for the intersex infant surgeries that became increasingly prevalent over the next century.

These surgeries, as well as concepts of gender and sexual identity, were pioneered and popularized in the mid-20th century by Dr. John Money, a psychologist and sexologist born in New Zealand. Dr. Money received a Ph.D. in psychology from Harvard University in 1952 and later became a professor of pediatrics and medical psychology at Johns Hopkins University. At Johns Hopkins, Dr. Money worked with endocrinologist Lawson Wilkins and psychiatrists John and Joan Hampson to create the Psychohormonal Research Unit (PRU), the first clinic dedicated to the research and treatment of “hermaphroditism,” or intersexuality. Here, Dr. Money studied over 100 cases of intersex conditions in both children and adults, allowing him to research deeper into what the “causes” were. He believed that there were six “variables of sex” or physiological components that made up the sex of a person– chromosomes, gonads, hormones, internal structures, external genitalia, and sex assignment– and sought to identify which of these variables, if any, were most responsible for a person’s gender identity (Delimata 2019). Money’s work centered largely around the “nature vs. nurture” argument, questioning whether gender is innate in an individual or formed by the social factors and pressure around them. The research conducted at the PRU was groundbreaking for its time, and Dr. Money’s theories brought up new questions about gender identity that society had never thought to consider.

Link to source image

Many of Dr. Money’s ideas, however, had deeper roots in what was previously believed about psychology and the origin of humans’ concept of gender. A significant amount of his justifications for intersex surgeries were based on the theories of Sigmund Freud, an Austrian neurologist best known for his (now discredited) ideas on personality, sexuality, and mental illness, as well as his creation of psychoanalysis. The book Articulating Intersex: A Crisis at the Intersection of Scientific Facts and Social Ideals by Natalie Delimata explains that Freud’s primary theory regarding the formation and source of gender identity was that “interaction of the body with the social environment and how the individual experienced this was important for psychosexual development,” and that “the genitals, in particular the presence or absence of a penis, were crucially important”; in other words, Freud believed that a child’s gender identity was a product of how they were raised and that the reconstruction of their genitalia (to either possess or not possess a penis) would inherently make the child align their gender identity with whichever sex they were assigned. Dr. Money adopted Freud’s theories in his studies on gender identity, subscribing to the belief that gender is not innate but instead can be changed through surgery and societal treatment. His studies conducted at the PRI surprisingly supported this theory, as only five out of the 105 studied “hermaphrodites” showed an identity that did not align with their sex assignment. Thus, Dr. Money used this as evidence that gender is malleable rather than innate and rigid, and that in cases of intersex youth, the child would identify themselves with the gender society viewed them as. Money also supported the concept of “genital unfinishedness” in intersex youth– that is, the idea that intersex children have a “true” sex that has not been fully developed in the same manner as other children, and therefore physicians have the ability to “complete” their genital development in alignment with this sex. 

One of Dr. Money’s cases, however, was revolutionary in how it challenged this common view of “malleable” gender. In 1966, a young biological male named David Reimer met with Dr. Money for the purpose of treatment of a severe injury to Reimer’s penis. Reimer was born with a minor medical genital defect for which a previous doctor decided to use circumcision, a procedure that removes the foreskin from a penis, as treatment– however, the circumcision was unsuccessful and Reimer suffered irreparable damage to his penis as a result. Dr. Money chose to treat Reimer by reassigning him as a girl, reconstructing his genitals into those of a female and having him undergo hormone therapy via the intake of estrogen. Reimer was never informed of this surgery and believed he was born biologically female during his childhood, which was done so that Dr. Money could prove that gender is not innate and could be changed after birth; therefore he believed that Reimer would live on as a woman without further considerations. This, however, was not the case. Throughout his life, Reimer showed signs of gender dysphoria, a sentiment of unease or discontent as a result of one’s biological sex not aligning with one’s gender identity. In his teenage years, after learning about the surgery, Reimer began to socially identify as a man and continued to do so in his adult life, disregarding his upbringing as a girl. Yet, he experienced extreme suffering as a result of his gender dysphoria (in combination with anxiety and depression), which eventually led to his suicide in 2004 at the age of 38 (Intersex Society of North America). This case became famously known as the “John/Joan” case.

This case was extremely important to the history of intersex surgeries in two ways. Primarily, it challenged the previously held views regarding intersexuality and gender that Dr. Money avidly promoted. Reimer’s choice to identify as male later on in life was proof that gender could not simply be altered or changed through a different upbringing or modified genitalia– his childhood as a female had no impact on his “true” or innate gender identity, and he chose to live as a man despite all efforts to reassign him. Second, it was the first example of how nonconsensual gender reassignment surgery could have serious consequences on mental health. Prior to the “John/Joan” case, there was little consideration given to how the infants that underwent operations for gender reconstruction would suffer psychologically– it was expected that, because their gender would align with their newly assigned sex, there would be no lasting damages to their wellbeing. The mental suffering experienced by Reimer, in the forms of gender dysphoria and depression, however, completely countered this point. Reimer’s suicide proved to physicians such as Dr. Money that gender reconstruction surgeries could not be taken lightly and could not be performed without proper considerations being given to the patient’s mental health. Thus, it was viewed as a significant blow to the medical field’s adequacy in treatment of intersex individuals, requiring a serious change in its approach and ideology.

Considering the history of intersex surgeries, how they first originated, and the conditions that were present when they began being practiced is an extremely necessary part of grasping the topic as a whole. While many of the societal ideas surrounding gender identity and its source have changed as scientific knowledge has advanced and the LGBTQ+ community has expanded, many of the justifications used for intersex surgeries are still present in the world today. The desire to make individuals conform to the gender binary and the desire to shape one’s gender simply because it is “convenient,” as was present in the “John/Joan” case, are still concepts used by parents and physicians alike to argue in favor of surgery, proving that even centuries later, the ideological foundations remain the same.

Informed Consent

Harry Wedel, NHGRI, link to source image

Arguably, the most relevant and heavily debated issue with the practice of intersex surgery has been the issue of informed consent. Informed consent is often defined as “the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention” (Shah et al. 2022). After being fully educated and informed, the patient can then provide their consent to the procedure if they are over the age of 18 and possess competence, which is an individual’s ability to make decisions regarding medical treatments. In the United States, a medical professional’s obtaining of the patient’s informed consent is legally required before any medical interventions occur, meaning that the patient must fully understand every aspect of the treatment and its potential harms and voluntarily agree to it (Stewart 2019). Informed consent is both a legal and ethical concept, as it was created out of the need to protect patient autonomy and ensure that medical procedures were being done in a manner that prioritized the stakeholder of the patient– informed consent for minors, however, is where ethics and law diverge from one another, especially when considering intersex youth. Minors (individuals under the age of 18) are not legally competent, meaning that they do not have the legal right to make decisions about their healthcare– because of this, they do not have the ability to provide informed consent until they turn 18. Instead, the parents or guardians of the child are responsible for giving informed consent on their behalf, approving of or denying the medical treatments that are suggested by the child’s physician. This policy is necessary in many instances, as extremely young children do not have the brain development to understand medical terms, the long-term risks, and the necessity of intervention.

However, the ethicality of this practice is complicated in the case of intersex surgery. Intersex surgery to change genitalia is almost never considered a “medically necessary” procedure unless the intersex child is unable to menstruate, urinate, or perform a function essential for survival without surgical intervention (Human Rights Watch 2017). Because this is not usually the case, and the surgery is done for reasons other than retaining genital functions, many intersex individuals feel as though parents should not be able to provide informed consent for these surgeries on behalf of their children. Advocates for intersex rights often argue that a decision as life-altering and serious as sex assignment should be postponed either until the individual is 18 and therefore legally able to provide informed consent or until the individual is old enough to approve of the surgery themselves, have a say in the sex they are assigned, and give their parents the “go ahead” to give informed consent on their behalf. Ethically, the lack of a legal requirement of the child’s consent is an infringement upon their autonomy, as it rids them of the ability to choose the course of action they wish to take and makes them subject to the courses of action chosen by others. Legally, however, parents are within their rights to make medical decisions for their child that they believe are necessary, and some feel as though the parent’s judgment and life experience qualifies them to make the decision, regardless of how significant it is. 

There is a counter-argument to be made in favor of parents providing informed consent for their children, specifically using the ethical value of responsibility. It can be said that parents have an inherent responsibility to protect their children from bullying, feeling ostracized from those around them, and to provide them with a happy childhood in which they feel safe and fulfilled. Yet, intersex children who remain with the genitalia they are born with face the possibility of being subjected to taunting or harassment from other children as a result of their differences, which is amplified in social and educational settings where interaction with peers is constant and the child is put into many situations where their biological sex matters (bathrooms, athletic competitions, etc). Further, as social media becomes even more prevalent and minors have increasing ways to spread hate and misinformation, parental concerns about their children’s mental health have grown significantly– a study conducted by Pew Research Center found that in 2023, around ¾ of surveyed parents reported concern for their child’s mental health. This emphasizes the parent’s responsibility to preserve their child’s mental well being– as children become easier targets for online or in-person harassment, and as paranoia surrounding safety grows, it could be said that the parent of an intersex child has the responsibility to consent to the surgery so as to protect their child.

Informed consent represents an area in which the law is not necessarily aligned with ethics, and brings up issues of autonomy that question whether the lack of necessity of informed consent under the age of 18 is even ethical at all. While the value of responsibility does have a major impact on the decision that is made, I firmly believe that autonomy cannot be sacrificed to preserve parental duties or to alleviate parents’ paranoia. Parents worry about the wellbeing of their children everyday– that is an indisputable fact– but by acting in what they believe to be the “best interest” of their child, they are ultimately doing more harm to them than good. While the surgeries prevent the child from experiencing the psychological damage that arises from bullying, they are, in doing so, leaving them with other forms of permanent trauma and physical pain that are lifelong. Is it worth sacrificing physical wellbeing to preserve mental health? Is the child’s mental health even being preserved in the first place? To answer these questions, we can analyze this issue using the principle of non-maleficence.

“Doing No Harm”

How Can Surgery Be Physically Harmful?

The bioethical principle of non-maleficence, or “doing no harm”, is another crucial piece to consider when analyzing the ethicality of youth intersex surgeries. While doctors have a responsibility to “do no harm” under the Hippocratic Oath, the principle can also be applied to the responsibility of the parents. Being responsible for the wellbeing of their child, they have an equal responsibility to mitigate harm for their children, and to carry out the actions that will produce the least amount of harm possible. Intersex surgeries carry a number of potential consequences or harms to the patient, all of which could be used as an explanation as to why they should not be performed. “Harm” can manifest itself in multiple ways, both physically and mentally as well as over a short period of time versus far into the future. “Harm” can first present itself through the direct impacts of the surgery on the child’s physical health and wellbeing. The most common consequences of surgery include permanent scarring on one’s genitalia as well as chronic pain and discomfort in the general genital region that is chronic in many cases. It can also result in incontinence, which is a loss of bladder control that can span from either minor bladder failure to a total inability to prevent or control urination (Human Rights Watch 2017).

These surgeries also carry other “harms” that are arguably much more severe. Genital-altering surgeries often require the severing of numerous nerve endings in the genitalia, which are irreparable. Significant nerve damage in the genital region results in the inability to feel sensation in this area, which in turn results in a lack of sexual sensation during intercourse. Further, the loss of gonads during surgery can often lead to sterilization (infertility) that cannot be reversed by any means, therefore preventing intersex individuals from having biological children (Human Rights Watch 2017). While it is often argued that intersex individuals are already infertile due to the condition they suffer from, this is not true– not all conditions resulting in intersexuality cause infertility. Thus, surgeries present new harms to intersex youth that they would not otherwise face.

How Can Surgery Be Psychologically Harmful?

Intersex surgeries have also been shown to induce serious psychological trauma in the individual undergoing the procedure, creating feelings of distress and long-term suffering. Anick, an intersex individual from the United Kingdom described the following when speaking to Teen Vogue about this aspect of the procedures:

“I was taught to hate my body from a young age. I was made to feel like I was a freak. Yet, I think what made my experience so unusual was that I looked perfectly fine to most people throughout my life. I was still in primary school when I began to understand that there was something about me that doctors found intriguing, but I couldn’t figure out why. All my scars were hidden. I never spoke about any of the medical stuff, because that would be admitting something was different. The truth was something I spent a long time hiding and I just wish I didn’t have so much fear. What hurt the most, aside from the surgeries and infections, was the idea that I would always be rejected and never comfortable in my own skin.” 

– Teen Vogue

These feelings of self-hatred, fear, isolation, and confusion are not just specific to Anick— rather, they reflect the experiences of many intersex individuals who were forced to receive surgery at an early age. In many cases similar to Anick’s, the physician’s “need” to “correct” the genitalia of an intersex individual often makes them feel “so freakish even their doctors could not speak the truth of their bodies to them,” (Intersex Society of North America) which in turn results in the individual feeling discontent or discomfort with their body and ostracization from society. Further, nonconsensual surgeries have proven to have a negative effect on the mental health of intersex individuals– statistics from the Trevor Project show that 7% more intersex youth than non-intersex LGBTQ+ youth experience suicidal ideation, and that ⅔ intersex youth report symptoms of a mental illness such as depression. The aforementioned 2018 study shows that 53% of surveyed intersex adults experienced fair or poor mental health, and showed clear signs of depression and anxiety disorders. The lack of consent given for these procedures also contributes to the psychological damage inflicted on the individual. When they are given little to no control over their body, their circumstances, and the medical actions that are taken going forward, they are put in a position where they are essentially powerless and are observing as those around them make major decisions that ultimately impact every aspect of their life. This often leads to a sentiment of a lack of control, a lack of trust in the healthcare system, as well a lack of trust and a feeling of betrayal in family members who consented to the surgery on the individual’s behalf. Thus, while parents believe that forced genital surgery would guarantee their child a happy, simple childhood filled with positive experiences and good mental health, the surgery often accomplishes the opposite.

Gender dysphoria, as shown in the “John/Joan” case, is another form of “harm” that has a significant role in the mental wellbeing of an intersex individual. While intersex individuals are not always forced to identify with the gender that aligns with their assigned sex, the surgery does make it significantly easier to force or instill a gender on the child in the long-term. Although some parents do not take further actions than the surgery, some may choose to then raise their child as their assigned sex and place them under hormone treatment, via the intake of testosterone or estrogen, which then changes their sex characteristics in ways other than just genitalia. 

When an intersex individual is forced to align with a gender that is different from that with which they identify, they are significantly more likely to experience suffering as a result of gender dysphoria. Gender dysphoria can also stem from societal perceptions regarding how one’s gender is viewed by others and discomfort or pain with certain parts of one’s body, and often has a major impact on how one views oneself. An individual who does not identify with their assigned sex may feel dysphoric not only because of their appearance but also because of the gendered stereotypes that are placed upon them, the gendered behavior they are expected to exhibit, as well as how their interactions with others are influenced by their perceived gender. For intersex individuals, this is extremely present, as the lack of input from the child makes it significantly more likely that the child will transition later on in life. Statistics from the Trevor Project show that 58% of over 1,000 surveyed intersex youth in the United States aged 13-24 identified with a gender that did not align with the gender they were assigned. This means that many within this  population of people likely also experienced gender dysphoria for some period of time in their lives before transitioning, as the need for transitioning, in many cases, stems from discontent with the assigned sex.  Although there is no way to ensure that one’s biological sex matches with one’s gender identity later on in life, surgeries increase the probability that an intersex individual will experience gender dysphoria because their sex was surgically assigned at random without their input. 

While physicians often use the Hippocratic Oath as a guideline for how to approach various medical scenarios, its application in cases of intersex surgeries is significantly more complicated. The Hippocratic Oath states that it is a physicians’ responsibility to “do no harm” to a patient, therefore following and upholding nonmaleficence– but which “harm” should be prioritized out of all of them? “Harm” could be defined as the physical harm of the surgery as well as the psychological damage that is created by gender dysphoria for those who do not identify with the gender they were forcibly given. Based on this definition, the physician would consider “doing no harm” to be not allowing the child to undergo surgery. However, “harm” could also be viewed as the mental complications that arise from being intersex in a society defined by and constructed around the gender binary. Locker rooms, bathrooms, health classes, and gendered schools are simply a few examples of situations in which a child’s actions are defined by their gender, and are locations in which an intersex child would likely feel severely uncomfortable due to their inability to “fit in” with those around them. Anick, a 24 year-old intersex individual from London, recounts his experience in his youth in an interview with Teen Vogue, saying that “My private parts looked visibly different, and I desperately tried to conceal this. I was mortified at the thought of someone finding out. I never admitted when I fancied someone, and I would always try to change into my gym clothes out of sight.” (Teen Vogue 2019) Young intersex children who are thrown into these scenarios likely cannot grasp the complexity of the situation and may only view it as a way in which they are different from their peers, and could even be subjected to taunting or bullying from classmates because of their physical differences. This might be classified as emotional or psychological “harm,” which, if the physician were to consider it as such, would mean that the physician would be under the moral obligation to perform surgery to mitigate this harm. Thus, the physicians’ responsibility becomes murky and largely differs based on which “harm” the physician believes to be more important or severe. 

Non-maleficence plays an essential role in the decisions of every single healthcare provider, physician, and parent, and is especially present when discussing intersex individuals because of the different ways in which it can be applied.  Non-maleficence requires one to consider both potential situations in which harm can be present, and questions what is more important or more necessary to prevent– the mental harm or the physical, as well as the long-term harm or the direct, immediate harm. Either way, both forms of harm are significant detriments to the patient’s wellbeing, arguably worsening their health and leaving them with more physical and psychological damage than they would possess without the operation. While parents may have good intentions when choosing to operate, there is no denying the permanent suffering the child will have to face as a result of their decision.

Determination and Assignment of Gender and Sex

Part of the issue with these surgeries, aside from the evident consequences to the individual’s health, stems from the fact that there is no scientific way of knowing how a child will want to identify later on in life. As a result of this, parents and physicians have created several different “methods” to assign a sex that is not just chosen at random, thus attempting to make their decision justifiable. First, many parents take a standpoint similar to that of Dr. Money in that they decide to assign the sex that seems the most “unfinished” or “likely to be present” in the child. For example, in the case of a child with an enlarged clitoris, a parent might feel obligated to surgically give the child a conventionally sized clitoris and raise them as a girl even if there is no concrete evidence that they would want to identify as such or that the surgery is in any way helpful.

Another conflict with how physicians choose to assign sex is that for some physicians, the choice is made solely based on “medical convenience”. In cases of ambiguous genitalia, it is usually significantly less complicated for a physician to perform “feminizing” surgery on the patient than “masculinizing” surgery. For example, vaginoplasty, which is the creation of a vagina using existing tissue from the individual’s genitalia, is said to be a “shorter and less complex intervention” than phalloplasty, which is the creation of a penis using skin and tissue from other parts of the body (Vancouver Coastal Health 2006). Because of this, a vast majority of intersex individuals are assigned female – the percentage of female-assigned intersex people is around 96% (Hausman 2000), meaning that physicians are more inclined to assign the child with a sex that is surgically easier to create. While choosing an easier procedure eliminates physical safety risks to the child, it demonstrates a lack of consideration for the child’s actual desires and an inclination to take shortcuts when providing medical care. Patients arguably deserve a high standard of care from their physicians regardless of how “difficult” or “inconvenient” it may be, yet this method of assigning sex treats the patient as dismissible and not worth the physician’s time and effort. 

Some parents take a unique standpoint in that rather than forcing the surgery upon the child immediately after birth, they instead choose to wait a few years before going through with the surgery. The hope is that in doing so, they are granted the ability to analyze the child’s behavior in their primary developmental years, during which their child will begin to show signs of “gendered behavior” that can help them assign the child with a sex and gender that they actually seem to identify with. Observing the child’s patterns of speech, friendships, clothing preferences, etc, are all examples of “gendered behavior” that many believe are indicative of the child’s gender identity. The key issue with this, however, is that this decision is largely based on gender stereotypes that have no correlation to gender identity. For example, a child may identify as a boy for the entirety of his life, but enjoy playing with dolls or wearing dresses in his early childhood– this does not mean that he is a girl or wants to be identified as such, but using behavior as an indicator of gender makes this assumption. While parents using this method are taking a larger step in considering the child’s desires, it is not the same as allowing the child to make the decision on their own. 

Further, many parents often fail to recognize that sex and gender are arguably not the same. While sex is defined solely by the genitalia that one is born with when assigning sex at birth, gender is an intrinsic identity and will not always align with one’s sex– in other words, an individual can possess a penis and be raised as a male yet identify as a woman if they feel so inclined. In the case of intersex individuals, many parents make the decision about their child’s genitalia out of a place of what they believe is necessity– they believe it is imperative that their child alters their body so they can “fit in” with their peers and among those in society who fit into the sex binary. However, when making this decision they simultaneously make paternalistic decisions regarding the child’s gender that are unnecessary. When a parent gives their child female genitalia instead of allowing the child to make their own surgical decisions if or when it becomes appropriate or relevant for them, they decide that the child shall also be raised as a girl to “match” the new genitalia they possess.  This presents a false dichotomy in which the child must either not receive any surgery at all or must receive surgery and possess a matching gender identity. Yet, studies have shown that gender cannot be changed on a whim, and therefore these parents can ultimately end up placing their children in uncomfortable positions where their true gender is not being affirmed. 

The idea that surgically assigned sex and gender identity should be kept separate can, however, be countered using the ethical value of stability. While allowing the child to grow up with the ambiguous genitalia they were born with also gives them the autonomy to choose a gender identity when they are ready, some claim that children need the stability of having a set gender in their early years. Children, being at a key developmental stage where they are building aspects of their character, physical and mental function, emotional intelligence, and their understanding of the world around them, need structure and stability in their lives. However, it is argued that not possessing a set gender might lead to confusion about who they are and how they fit into society, thus creating mental instability. If the child does not understand who they are or feels confused about themselves, it could distract from other key aspects of life that children should be prioritizing instead, such as education and social interaction. Further, gender identity is an extremely complex concept that many are unable to fully grasp and understand until they are in or past the adolescent stage. Children who lack this understanding may try to deal with their personal issues regarding gender without fully understanding what it is and how it works, and this level of internal reflection could potentially lead to mental health complications if identity becomes a main source of stress in the child’s life. Many believe that surgery is necessary in order to preserve the child’s mental stability and development, even if they also consequently end up forcing their child into a gender identity they do not possess. 

While considerations for the child’s desires can and should have an influence on a parent’s decision, they are often overshadowed by coercion from physicians, as “many doctors have defaulted to advising early irreversible surgery on intersex children” (Human Rights Watch 2017). Despite the fact that families choose to put full trust in their physician to deliver objective and unbiased advice, the physician unfortunately does not always do this, and often pushes the parent to approve the surgery through encouragement or threats. In some cases, physicians may use the possibility of poor mental health as a threat, telling the parents that not having surgery would make their child stand out amongst their peers and feel “abnormal” around other children. The physician takes advantage of the parent’s desire to care for their child and illustrates a future in which their child is miserable and ostracized from those around them, thus leading the parents to choose surgery without explicitly telling them to do so. Coercion for intersex surgeries from a physician is not a rare case, as the Trevor Project states that “Intersex youth reported twice the rate of having had a mental or physical healthcare provider attempt to convince them to change their sexual orientation or gender identity compared to LGBTQ youth who are not intersex”. 

While each method for assigning sex is different in terms of its justification, reasoning, consequences, and stakeholders, they are all scientifically inaccurate and unhelpful when attempting to assign a sex to the child. Some parents and physicians do not attempt to make the assigned sex align with the child’s “desired” sex entirely, focusing on convenience and physical appearances rather than emotional intuition and behaviors exhibited by the child themselves. However, even the methods that are used to “understand” and “identify” the child’s “true” gender are unreliable and have no basis in fact, and therefore cannot be used as an effective way to bring the child’s desires into account. Coercion from physicians and the constant threat of the safety of the child being compromised as a result of not undergoing surgery presents another challenge when attempting to make an unbiased and objective decision, and a lack of understanding about the modern definitions of terms like “sex” and “gender” makes it even more difficult for a parent to accurately assess the necessity of medical intervention. These are all large issues that add a level of nuance to the intersex surgery dilemma, and are all necessary things to consider when thinking about the perspective of a parent and why a parent may choose to have their child undergo surgery despite the possibility of a negative outcome.

Ethical Analysis

The practice of youth intersex surgeries can be classified as an ethical dilemma, as ethical dilemmas often include two conflicting options or potential decisions, both of which can be considered as the “right” thing to do depending on how the situation is viewed and what values are taken into consideration. The essential ethical question that arises from this is, is it ethical to perform non-life-saving genital reconstruction surgeries on intersex youth without their informed consent? 

Morgan Carpenter and Intersex Human Rights Australia, link to source image

Some of the ethical values that can provide guidance on how to answer this complex question include the values of autonomy and equality. Autonomy is defined as the right or ability to self-govern and make choices for one’s own self. Intersex surgeries breach upon the autonomy of young individuals in multiple ways, primarily their autonomy over the presentation of their gender identity. As previously mentioned, many parents do not understand the difference between sex and gender, and choose to assign their child to a gender at the same time as the genital reconstruction surgery is performed although gender is not something that can simply be “assigned” in this manner. Thus, there is a greater emphasis placed on the child identifying with that gender and behaving in accordance with it, even if it is not who they truly believe they are, and the flexibility to identify with a different gender early on in life is not as present. The child grows up knowing that there is an expectation for them to behave a certain way based on their parents’ and physician’s desires, and therefore will be significantly less able to voice their thoughts about who they truly are. Thus, the child is stripped of their autonomy over gender identity. While not performing the surgery nor forcing a gender upon the child would allow for them to autonomously choose what gender they wish to present themselves as, forcing surgery restricts this freedom of choice.

This is complicated even further when considering the irreversibility of the surgery. The vast majority of genital reconstruction surgeries are irreversible, in that “tissue or organs that are removed cannot be replaced, nerves that are severed cannot be regrown, and scar tissue can limit options for future surgery” (Human Rights Watch 2017), meaning that once the genitalia has been created, the individual cannot get any other surgery to change it, even if they do not feel comfortable with it. In this case, the individual is not given any autonomy to change the outward appearance of their sex later on in life, despite the severe discomfort and gender dysphoria it may cause them. This strips them of a large amount of autonomy over their gender presentation that they may have had had they not been forced to undergo surgery, and can also create lasting impacts on the individual’s mental health as a result of inability to relieve gender dysphoria. While they can change their outward appearance in other ways, surgery is still a significant option that is taking away from them. 

Surgeries also infringe upon the individual’s autonomy through some of the lasting effects they cause, such as infertility and lack of sexual sensation. Both of these are, for many, key aspects of life that one is robbed of when the surgery is performed. The sterilization caused by the surgery is a clear infringement upon one’s right to their own reproductive health decisions, preventing one from having biological children without taking one’s desires into consideration in the process. Further, autonomy over sexual experiences has historically been a major issue with intersex surgeries as the surgeries limit one’s ability to have sexual experiences in the same manner that non-intersex people would. A study conducted on XY chromosome-possessing individuals with disorders of sex development who had undergone genital reconstruction surgery showed that 47.4% of 57 people surveyed felt dissatisfied with clitoral arousal, and 47.1% were dissatisfied with the function of their assigned genitalia (Köhler et al. 2012). For many, these are major losses that are solely a result of the surgery, none of which they were able to choose for themselves or have a say in. 

This issue can also be viewed using the value of equality, which requires one to question whether all individuals are being given equal rights, opportunities, and advantages. It can be said that because genital reconstruction surgery is almost never medically necessary for the child, it is instead being performed out of a desire to “correct” the child and “fix” what society considers to be a serious defect. Yet, to operate on an intersex child is to imply that intersex people are inherently “less than” or below other people and instead need correction to match the appearance and identity of those around them. Further, the lack of necessity of informed consent before performing surgery can be considered as an infringement upon their rights, an infringement that non-intersex individuals do not have to experience unless there it is a genuine medical necessity. Providing non-intersex people with greater rights over their medical decisions and autonomy is unequal, and suggests that intersex individuals do not “deserve” the same level or standard of care as those around them. This parallels disability rights in many ways, as a large issue with the medical model of “correcting” or “fixing” disabilities is that it suggests that disabled individuals are “defective” and require surgical correction to function in society– but again, viewing any group of people as defective or unnatural is unjust and unequal, and therefore cannot be viewed as ethical from an equality standpoint. 

An ethical framework that can be applied to intersex surgery is consequentialism, which analyzes the ethicality of an action or practice based on the consequences or outcomes it produces. While the surgeries have obvious negative consequences on the individual’s health, there is also an unintended consequence in terms of the precedent that the surgeries set. When society deems intersex surgery as an acceptable practice, it creates the potential for a slippery slope in which it becomes acceptable to change every person who is biologically different simply so that they can fit the current “norm” or standard. While at the moment it may only extend to intersex individuals or individuals with disabilities, if society continues to change the appearances of individuals solely to encourage conformity,  what is different, then, about requiring cosmetic surgery for people with different face shapes, body types, or coloration? If there is no medical need for intersex surgeries nor is there a medical need for cosmetic surgery, then what is the differentiating factor. Allowing for intersex surgeries to continue perpetuates a society in which there is a standard for how people should appear, and thus can create the consequence of requiring a set “appearance” for all people even where there is no direct need. Thus, using a consequentialist lens, this unintended outcome would make the action unethical.

Conversely, when considering the ethical argument in favor of intersex surgery, virtue ethics creates an interesting contrast to the framework of consequentialism, considering one’s character and motivations to be more important in determining the ethicality of an action than the produced outcomes. Virtue ethics judges whether one’s actions are ethical based on whether it is in accordance with certain virtues and positive character traits, and can be applied to intersex surgeries when considering the decision of the parent. While not all parents have entirely pure intentions when requiring surgery for their intersex child, a vast majority of them are motivated solely by the stability and wellbeing of their child. The topic of coercion touches on this briefly– parents who have significant concerns about their child experiencing negative treatment from peers and society are more inclined to act in favor of the surgery, as they genuinely believe that they are doing what is best for them. The intention behind this action aligns closely with the virtue of benevolence, which is the quality of being well meaning, as the parents are trying to benefit the child even if that is not the ultimate result. Therefore, because virtue ethics focuses on the virtues that motivate a judgment or choice, it would claim that surgery is a justifiable decision for the parents because their actions align with the virtue of benevolence. 
Using ethical values to analyze the final ethical question clearly presents the issues and problems present with the surgical practice. Surgeries for young children do not permit the child to elect for further surgeries in the future, reducing their autonomy over gender presentation. Operating on one specific, targeted group of people without medical necessity promotes inequality in the healthcare system, and ultimately creates a world in which we find it acceptable to change the appearances of anyone who does not fit into our societal “norm” or standard. While other values can be used to counter this idea, an analysis using the values of autonomy and equality in combination with a consequentialist framework would ultimately not be in favor of continuing the practice, thus deeming it unethical altogether.

Conclusion

While the world has been unable to come to a consensus when discussing whether these surgeries are ethical, despite the fact that intersex people largely agree that they are not, it has also faced the same issue when determining whether the procedure should even be legal to begin with. Currently, youth intersex surgeries continue to be legal and available in many regions regardless of the complicated and questionable ethical implications. While there is no nationwide ban against them in the United States, several other countries do not allow for the practice to occur, such as Malta, Germany, Switzerland, Australia, Chile, and others. The United States has instead turned to statewide legislation to determine whether the surgery should be legal, and therefore the legality of the surgery differs between states and the political climate of each state. In states that tend to vote in favor of Democratic candidates, laws against surgery are either currently in place or in the process of being created. In 2019, California attempted to pass a bill that banned non-consensual and irreversible intersex surgeries until the age of 6, at which point the family and child would be able to choose surgery if they so desired. However, pushback against the law due to lack of flexibility for each individual patient as well as doubt regarding the “correct” age for surgery resulted in the bill being discontinued (New York Post 2019). In New York, another blue state, New York City Health & Hospitals (one of the largest healthcare providers in the United States) created a policy for physicians to defer medically unnecessary surgeries on intersex children (Human Rights Watch 2021). Further, a bill was proposed in 2019 to ban these surgeries altogether, which is currently in the process of being approved. 

However, states that vote in favor of Republican candidates and tend to hold more conservative values are less restrictive. In March of 2023, lawmakers in the state of Georgia advanced a bill that sought to ban gender-affirming care, such as hormone therapy and surgery, for children, which is meant to prevent minors from being able to medically transition. However, there is a specific exemption from this ban for intersex children that allows for their parents to still force surgical procedures on them without consent– despite the fact that this falls under the umbrella of procedures covered by the bill. This action has created extreme controversy among LGBTQ+ youth and intersex advocates, as it actually backs and supports the action in a legal context. This essentially means that Georgia is displaying support for the surgeries. Member of intersex advocacy group InterAct Bria Brown-King summarizes the opinion of many intersex individuals with the question, “So you’re saying that trans kids are too young to consent, but intersex kids aren’t? How does that make sense?” (PBS 2023). While certain states are taking action to protect the intersex population, political polarity makes this increasingly difficult for those who do not live in blue states, which is proven by the Georgia legislation. Ultimately, the lack of nationwide laws creates a split country in which there is no standard of care for intersex people, and therefore their rights are up for debate in many states and extremely reliant on the beliefs of state legislators and politicians. 

Bojan Cvetanović, link to source image

To determine what the best possible solution is to this issue, looking at the efficacy of nationwide legislation in other countries is extremely helpful. In 2013, Germany passed a law that allowed for parents of intersex children to not mark a specified sex on their child’s birth certificate, therefore not requiring or encouraging nonconsensual surgery. While this was done with the intention of reducing the number of surgeries that took place, in reality it did little to change the rate of surgeries that occurred per year. A study recording the number of genital surgeries on children in German hospitals between 2005 and 2014 showed that from 2012 to 2014, the frequency of “feminizing” surgeries showed “no significant decline,” while the number of “masculinizing” surgeries actually increased (Organization Intersex International Germany 2017). These rates suggest that even the implementation of policies relaxing the requirement for an assigned sex do not actually contribute to preventing the practice of intersex surgery. Then, in 2021, Germany passed a bill that outlawed youth intersex procedures altogether– however, this raised many concerns regarding loopholes that could be used to bypass it, as well as a lack of consequence for disobeying the law. One way in which the law could be circumvented is by not actually giving the child an intersex diagnosis, as the law would technically not be applicable to them (Anarte 2021). Some diagnoses involve ambiguous genitalia but are technically not considered to be intersex variations, which would therefore allow for a surgical procedure to occur. Germany also does not currently have an outlined punishment or legal consequence for those who illegally force surgery upon their children, which does not effectively discourage people from pursuing the operation (Middleton 2023). They have also not implemented any method of monitoring physicians’ compliance with this law (OII Europe). 

Although legal bans have the potential to save hundreds of thousands of intersex children from the permanent harms of surgery, the lack of structure and definition in these laws makes them currently inadequate and unable to create real change. However, while it is important to encourage firmer, more serious legislation, it is also crucial to recognize the effort that is being put into intersex advocacy and protection, and the progress that has been made since intersex surgeries were first introduced. While they may be small steps, the actions of individual states as well as foreign nations are still steps in the right direction.

It is important to note that legislation is not the only way in which the autonomy, safety, and equality of intersex individuals can be preserved. When considering the aforementioned counter-arguments that argue in favor of genital reconstruction surgery, many of them share a common theme– the fear that an intersex child will not fit into society and will struggle with being viewed as an equal by their peers. But, where does the unwillingness of others to accept their intersex classmate even come from? The answer is, it comes from a lack of awareness, a lack of education, and a lack of understanding of what life is like for those who live with intersex variations. When people do not understand what it means to be intersex, they retaliate against intersex individuals out of a fear of the “unfamiliar”. There is no legislation that can fully and effectively prevent a child from experiencing hate or make a child feel as though they belong in a space– but, proper education and information can transform the opinions and ignorance of those who make them feel ostracized. Educational programs that seek to inform the public about what being intersex means, the incorporation of intersex and LGBTQ+ education into school health classes, and greater financial support for intersex advocacy organizations are all potential solutions that can help intersex children feel comfortable in public settings. In terms of preventing bullying from classmates, schools can create policies explicitly banning discrimination and harassment against intersex students. To decrease the discomfort an intersex individual faces in gendered settings, schools can also work to install gender-neutral bathrooms, sports, changing rooms, and encourage faculty to learn and respect the gender identities and preferences of their students (U.S. Department of Education). Although these are not major alterations, nor will they eliminate the practice of intersex surgery as a whole, any effort to make an intersex individual feel more comfortable in their surroundings still pushes back against the sex and gender binary from which the “need” for surgery arose in the first place.

Youth intersex surgery is a complicated, multifaceted, and ever-changing issue that continues to be a popular topic for debate centuries after its creation. It encompasses some of the most central bioethical topics such as informed consent, non-maleficence, the responsibility of a physician, and the duty of a parent when making medical decisions for their child. Using society’s view of gender, its origin, its historical relevance, and how it is determined or assigned in a medical setting, the ethical considerations of intersex surgery question the extent to which a child deserves autonomy over their body and the surgical procedures that are used to alter it.They force us to face societal stigmatizations of physical differences that cause people to deviate from what is considered to be “normal,” and address whether or not these people should have to conform to a certain standard simply so they can fit in. Yet, this analysis also requires us to consider the role of a parent and a parent’s inclination as well as responsibility to do what they feel is best for their child. How do we balance the needs of the child with the growing anxieties of parents in a modern society? To what extent should a parent get to make life-changing decisions for their child, and are there exemptions to that boundary? While these are challenging questions, the progress made in intersex youth and surgical procedures proves that our society is on track to finally answering them, and ensuring a positive medical experience that upholds the bioethical principles for all.

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