surprise! it's an intersex issue and nobody is talking about intersex people
Clitoral surgery: FYI and a chill pill
So I've seen a lot of people online getting into an uproar about this Cornell University study by Yang, Felsen, and Poppas called "Nerve Sparing Ventral Clitoroplasty: Analysis of Clitoral Sensitivity and Viability" published in 2007. You can read the paper here.
Dan Savage has posted a harsh rebuttal, as has Dreger and Feder at the BioEthics Forum and several people on my flist have ranted about what seems to be medically sanctioned genital mutilation on young girls and psychologically traumatising follow-up procedures involving a vibrator.
Sounds horrifying, right? I was astounded that such a thing could be sanctioned by a distinguished Western medical establishment's ethics committee. So you know what I did?
I read the paper. Carefully. And I conclude that many people have severely misunderstood what is actually described there.
Now I am only a medical student, I am not a qualified assessor of papers, I am unaware of any statements issued by the authors, their patients, or Cornell University. And I am certainly not condoning FGM or the practice of inappropriately sexualised procedures on youngsters. All I did was carefully look at the methodology of this study, and I hope I can put it into some logical context for you guys who may not be aware of the medical aspects involved.
Why do the surgery?
There were 51 patients involved in this study. 46 of them had the condition Congenital Adrenal Hyperplasia, 3 were male-to-female transgendered women, and 2 had other sexual development disorders.
These are NOT healthy girls with healthy large clitorises. Congenital Adrenal Hyperplasia is a life threatening condition at birth, and immediate management is required to dampen down or remove the abnormal adrenal glands. One of the unfortunate consequences of C.A.H. is that babies are born with ambiguous genitalia - I don't just mean enlarged clitorises, I mean that the ambiguity is so marked that you can't tell if the baby is male or female. It can manifest as having a narrowed or absent vagina, labia that look like scrotal sacs, and a long clitoris that actually looks like a little penis.
Standard practice in the long-term management of C.A.H. is firstly to serve the health needs of the child, and then look to surgically fix their genitalia. According to the paper, the primary inclusion category was that all these girls had "clitomegaly associated with ambiguous genitalia." So it's not just that these girls were having clitoroplasties alone. I wouldn't be surprised if many, if not all, had other surgeries to give them a functional vagina and to remove scrotum-like sacs from the labia. The fact that this study only reported the success rates of clitoroplasty means nothing.
In addition, having a large exposed clitoris can be very uncomfortable for a child, and if you consider the psychological ramifications of a young girl growing up and developing their gender identity when they have a half formed penis and scrotum.... well, you can see the indications for surgery right away. And particularly, the indication for surgery at as young an age as possible so that the child has no memory of it.
What about the follow up procedures?
I've already explained the need for surgery in the first place, I then carefully looked at the methodology of this study's follow-up, and I have a few explanations.
Clitoral nail bed perfusion test: A lot of people have misinterpreted this *hugely* - no, the doctors did not press their fingernail into the clitoris. Perfusion testing involves lightly pressing on healing tissue until it blanches, then releasing it to see how quickly the blood comes back. Try it on your own finger tip, you don't need much pressure at all. It is essential to do this to make sure the tissue is healing well and doesn't become necrotic or gangrenous. The nail bed test is done by doing the same thing on a person's fingernail, to see how quickly the blood comes back - the doctors here were comparing the perfusion of the newly healed clitorises to the patient's own fingernail blood supply.
Clitoral sensitivity and vibration test: Now here's the biggy. A lot of people have been concerned that this testing of sensation (using a cotton swab and then a vibrator) was being perpertrated on these young girls in a medical setting with their parent(s) present, and that such a situation would cause grievous psychological trauma.
And I agree with you. But I don't think that's quite what happened. If you look at the statistics, only 10 of the 51 patients were over the age of 5 and had the sensory tests. The oldest girl having these sensory tests was 24 years old, and therefore must have given informed consent. So the remaining 9 girls who had the tests could be anywhere from 6 years old to 24 years old.
I haven't seen any reports from the girls or their parents involved in this study, so please do correct me if you have information, but I cannot envisage any ethics committee approving the use of vibrators on pre-teen girls who cannot give consent. By which I conclude that the remaining 9 girls of indeterminant age who had sensory testing (hopefully) must have been at least over 13 years old and therefore able to give informed consent. Unfortunately I don't know statistics well enough to analyse the standard deviation and whether it gives an indication of the ages of those older girls involved (for those who may be able to help, the mean age and SD is 4.6 +/- 6.8 years).
Maybe that's naive of me, but I for one have faith in the ethical integrity of Western studies dealing with human subjects, especially over such a sensitive and inflammatory arena as genital surgery in minors. Who knows what is really going on behind the scenes with this paper, for all I know Yang, Felsen, and Poppas are evil disgusting people. But I at least wanted to share my analysis and some background info about the indications for clitoroplasty.
Some things I would really like to know that unfortunately weren't detailed in the study:
- How old the girls were who had clitoral sensitivity testing
- What genital surgery the patients had other than clitoroplasty
I hope I've helped people to gain a little perspective on what I percieved as the scope and intentions of this study. Thanks for reading, and if you have any further information to counteract what I've said, please do let me know. :)
source: lizardspots on LJ
This is exhibit #2748275982 about why you should never, ever, ever take Dan Savage's word when it comes to anything related to women, intersex people, or anything else, frankly.
note: lizardspots is herself (rightly) called out by an anonymous commenter:
In addition, having a large exposed clitoris can be very uncomfortable for a child, and if you consider the psychological ramifications of a young girl growing up and developing their gender identity when they have a half formed penis and scrotum.... well, you can see the indications for surgery right away. And particularly, the indication for surgery at as young an age as possible so that the child has no memory of it.
This right here? Is an example of your incredible cisprivilege, and I think you need to step back and take a look at what you're actually saying. It's incredibly offensive to the intersexed community, of which I am part of, and also why I am posting this anonymously, because I really don't feel that I should have to be outed to LJ at large to post this.
I support surgery that has to be done in order to help the child be normally functioning for their physical health, such as surgery to correct problems with the urethra. But to come out with this hogwash about how it's 'psychologically damaging' for children to grow up with genitalia that is not matching the stringent guidelines outlined in a medical textbook is disgusting and incredibly offensive.
Children should be allowed to decide for themselves if they want genital reconstructive surgery, and which gender identity they wish to align themselves with. While doctors may be right in some cases, in a large number they are not, particularly because they decide the child's gender identity largely based on the size of the cliterophallus. Most cases have nothing to do with the chromosomes of the child and everything to do with the heterocentric notion that the child, if allowed to be 'male' will have an unhealthy sexual life because his penis will not be able to pleasure a woman because it is too small.
It is far, far more traumatizing to be given a gender identity you do not want and to have your genitals hacked apart before you are really cognizant of them as an adult. Many, many intersexed could have had much happier lives with genitals closer to those that they really wanted, and happier childhoods without the pressure to conform to an applied gender identity that did not fit them. This also touches on transphobia, because many people cannot deal with the idea that a child should be free to choose what gender they ascribe to. Contrary to what may be a common belief, if a child is given guidance about the nature of their genitals, they'll deal with it pretty well. Children are really more flexible and strong than most people given them credit for.
I admit that this may or may not have anything to do with the study. I am not going to delve deeply into it because it is incredibly triggering to me to discuss genital reconstruction of infants with people I am not close to. But the language you use throughout your post, and the part I have highlighted are extremely hurtful and they do not fit with the sort of attitude that I would like to see from emerging physicians, especially those who express an interest with working with small children who may be forced to confront these sort of conditions.
It's better to champion the autonomy of these children as people than to mutilate them in order to make others, who should not need to concern themselves their others' genitals at all, more comfortable.
please take this commenter's words to heart and realize that we had a whole thread full of angry outrage primarily from cis women (i.e., people who are not affected by this procedure), and the word "intersex" was not even discussed even in the many letters which were published. please, please check your ignorance and your privilege. stop erasing intersex people from a controversy about intersex people.