Delay Gender Reassignment, Say Surgeons

21 February 2005
Delay Gender Reassignment, Say Surgeons
by George Atkinson

New research suggests that gender, often said to depend on anatomy or hormones, may depend also on hard-wired genetics. The findings may help doctors and lawyers better understand the one in 4,000 babies born with ambiguous genitalia (both male and female traits). "The biology of gender is far more complicated than XX or XY chromosomes and may rely more on the brain's very early development than we ever imagined," said researcher Eric Vilain at the American Association for the Advancement of Science Annual Meeting.

"Surgical sex assignment of newborns with no capacity to consent should never be performed for cosmetic reasons, in my opinion," said Vilain, director of research in urology and sexual medicine within the David Geffen School of Medicine. "We simply don't know enough yet about gender to be making surgical or legal assumptions."

William G. Reiner, also speaking at the meeting, agreed. "The most important sex organ is the brain," said Reiner, an associate professor in the Department of Urology at Oklahoma University. "We have to let these children tell us their gender at the appropriate time." Reiner said that an estimated 1 in 4,000 babies may be classified as "gender ambiguous" because intersex conditions affecting their genitalia, reproductive systems or sex chromosomes make an immediate assessment impossible.

Various conditions can cause genital ambiguity. A condition called Congenital Adrenal Hyperplasia in genetic girls results in prenatal exposure to androgen, the steroid that triggers male development. Genital features of girls born with Congenital Adrenal Hyperplasia may appear to be male. In other cases, collectively known as Androgen Insensitivity Syndrome, genetic males may have female characteristics when a mutation of the gene that encodes for the androgen receptor results in resistance to androgen's masculinizing effects during development. The timing of exposure to androgens in the uterus may result in ambiguous genitalia.

Of Reiner's patients, those who are genetically male will tend to identify themselves as boys if they can react and respond to male hormones, and even if they are born without a penis, underwent surgical reassignment and were raised as girls. "These children know who they are. It's encouraging that many more surgeons today are choosing to postpone surgical gender assignment until the patient is mature enough to take that step. Of course, social and legal gender assignment still must be carried out at birth," said Reiner.

Legal expert Susan Becker of the Cleveland State University told the meeting that U.S. laws assume that everyone is clearly male or female. "The U.S. Constitution promises equality, rights and benefits for all citizens," Becker said. "But, as the Constitution is structured and interpreted, individuals who do not meet the binary definition for male versus female don't have the same benefits and aren't completely protected from discrimination. In U.S. society, sex, sexuality and sex appeal is used to sell everything from toothpaste to cars. It seems that we can handle sexual caricatures in the media and sexually explicit movies, but we aren't equipped to have open, honest discussions regarding sexuality and gender. The time has come to move beyond our discomfort to engage in more product dialogue, informed by the best possible scientific information."