Argue #4intersex: Responses to Common Pro-Surgery Statements
The majority of people born with variations in their sex characteristics
do not require medical intervention in order to lead happy, healthy lives.
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Although the majority of intersex traits do not require surgery in infancy,
physicians may attempt to “fix” what isn’t broken by performing surgeries
such as clitoral reductions, vaginoplasties, and gonadectomies before thesechildren are even old enough to speak. These procedures often cause
irreversible harm to their reproductive and sexual organs, includingsterilization. Every major human rights organization that has considered thisissue, including the United Nations, the World Health Organization, andAmnesty International, as well as GLMA: Health Professionals Advancing
LGBT Equality, has concluded that surgeries should be postponed until theindividual can participate in the decision-making process. Intersex activists
have been asking for the practice of unnecessary childhood surgery to stopfor decades, yet it continues.
Rather than rushing irreversible decisions that limit children’s futures,
best practice dictates that families should have access to psychosocial
support and peer resources to help them cope with any distress or questions
they may have. The small group of physicians who perform these surgeries
oppose the suggestion that infant surgeries should be postponed until aperson can participate in decisions—but they owe it to their patients to do noharm. The focus of intersex medical care should transition from operating on
unconsenting children to treating consenting adults, who ironically lackaccess to competent health care because of the medical community’s focus
on childhood surgeries.
Why Some Physicians Oppose Efforts To Protect Intersex Children
There is a growing recognition in the medical field of the importance ofprotecting the bodily autonomy of intersex children. Even the American
Medical Association Board of Trustees recommended a delay of allprocedures unless they are necessary to address a life-threatening risk. But
some physicians feel that early, non-consensual surgeries such as clitoral
reductions and vaginoplasties should continue to be performed on infants
despite a lack of evidence to support such interventions. Here are a numberof common arguments presented by the proponents of intersex genital
mutilation, sometimes to convince the parents of intersex children to consent
to surgery, and sometimes to defend the practice to others:
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interACT supports the provision of surgical options in any life-threatening situations.

STATEMENT:

These surgeries are safe.

THE TRUTH:
Like any surgery, these procedures carry risks—including
risks associated with anesthesia. Recent research shows poorer
developmental outcomes among children exposed to anesthesia
before the age of four, and the FDA​ ​issued a warning​ in 2016 thatanesthesia could cause serious damage to the developing brain—yetthese surgeries are frequently carried out in infancy, within this zone ofrisk. Additional dangers specific to intersex surgeries are covered below,
including pain, incontinence, loss of sexual function, scarring,sterilization, and the potential for incorrect sex assignment.
STATEMENT:

These surgeries are reversible.

THE TRUTH:
Simply put, cutting nerve-heavy tissue will cause
irreversible damage. Scar tissue functions differently than tissue thathas not been operated on, and anything moved, or removed, during aprocedure performed on a child will grow differently than somethingthat has not been surgically altered. It is common sense that a clitoral
reduction cannot be reversed, nor can a sterilizing gonadectomy.​ ​Notethat doctors sometimes claim a procedure can be “reversed” when
what they mean is that additional, different procedures can be
performed later in an attempt to achieve a different outcome (such as
performing a phalloplasty on an individual who previously underwent a
clitoral reduction). This is patently misleading since these subsequent
procedures come with their own costs and risks, and they can neverundo previous damage or restore the body to its pre-surgery state. In
addition, earlier surgeries may limit options for future surgeries that
may be desired when tissue has been removed or reshaped once (ormore) already.
STATEMENT:The old surgeries were harmful, but the ones we
perform now aren’t.
THE TRUTH:
No amount of technical advances will change that theseprocedures violate a child’s human rights. You need only review current
medical literature, in which doctors advise procedures such as
performing unnecessary vaginoplasty surgery on six-month-olds, torecognize that these claims are meant to distract from the issue of
unaddressed human rights violations. Additionally, doctors have been
confidently announcing “improvements” in surgery for decades, butlack evidence to support those claims.

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STATEMENT:
families.

We are following the guidance of these children’s

THE TRUTH:
Parents are horrified when they learn that a procedure
offered as an option for their child has been deemed a form of tortureby the United Nations—but they weren’t made aware of that
information by the physicians caring for their child. Treatment teams
may direct parents to surgeons for procedures before educating them
about non-surgical options, and many parents of intersex children
report being pressured into decisions without full information about
the risks of these surgeries or the option to delay or refuse them. When
doctors fail to fully inform parents about the risks and all viable options,and then claim they are heeding the parents’ wishes by performing
surgery, it is disingenuous. Moreover, there are limits on the rights ofparents to make decisions for their children. Doctors know they are notpermitted to perform just any procedure on a child simply because aparent requests it—for instance, female genital cutting is prohibited bycriminal law, unnecessary sterilization is unconstitutional, and cosmetic
surgery such as breast enhancement or rhinoplasty on a young childwould not seem reasonable to a practicing physician. It is valid forparents to have concerns about raising a child with an atypicality, but
this is best addressed by offering psychological care and support, notirreversible surgery on their child.
STATEMENT:
for each child.

A team of experts carefully determines the best option

THE TRUTH:
All experts agree on the importance of a “multidisciplinaryteam” made up of specialists from different areas of medicine,including psychology. However, we hear from families of intersex
children that they lacked access to someone who could explain therealities of living with an intersex condition—including that children
can grow up healthy and happy without surgery—and the potential
ramifications that surgery may bring about. Encountering a team ofphysicians without a centralized advocate can result in parents feelingoverwhelmed and pressured to make decisions without understanding
all of the information. While surgeries are being recommended for“psychosocial” reasons, mental health specialists are often not involvedin the decisions, or are involved only after the decision to proceed withsurgery has already been made.

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STATEMENT:
options.

Physicians/Parents should be allowed to consider all

THE TRUTH:
Parental choice is not limitless, even in medical contexts.
For example, physicians would not recommend, or allow a parent toconsent to, a sterilizing procedure on an infant just because the BRCA
gene (correlating with a higher risk of reproductive cancers) is present.
These procedures should be considered from the perspective ofpreserving the child’s ability to make their own choices later, rather
than from that of promoting a caregiver’s ability to make decisions on
their behalf. In most areas of medicine, the least invasive option isalways considered first. Physicians and parents should err on the side ofpreserving all possible options, since they have no way to determine
what the intersex child will want in the future.
STATEMENT:We can now reliably predict a child’s gender, and“gender assignment” (previously referred to as “sexchange”) operations are no longer performed.

THE TRUTH:
Just like with a non-intersex child, a physician cannot everpredict that a child will not be transgender. For intersex children, thelikelihood that they will identify with a gender other than the one
assigned can be as high as 60% depending on the condition—but even
if the assignment turns out to be correct, there are plenty of distinct
harms associated with surgery. Some doctors claim, for instance, that it
is not “assigning” sex to perform a clitoral reduction or vaginoplasty ona child with Congenital Adrenal Hyperplasia since these children
usually identify as girls—but these procedures wouldn’t berecommended in the first place but for a female sex assignment, and inany case, unnecessarily removing clitoral tissue is just as harmful
whether or not the child later identifies as a girl. Pain, loss of sexualfunction, PTSD, urinary problems, and many more risks apply
regardless of whether a given procedure is seen as “assigning” or“changing” a child’s sex.

STATEMENT:4 ​Argue #4intersex

These surgeries are just restoring “normal” anatomy.

THE TRUTH:
There is a great deal of variation in genital anatomy.
Difference alone does not mean surgery is necessary, and it certainly
doesn’t mean surgery is necessary before an individual can say how
they want their genitals to look or function. This is why, for example,
The North American Society for Pediatric and Adolescent Gynecology
recommends against surgical intervention on genitalia even foradolescents, and instead suggests first exploring psychological care toencourage bodily acceptance. In addition, many childhood surgeries
attempting to fashion “normal” anatomy do not serve a function. For
instance, a common urogenital sinus (where the vagina and urethra are
not separated) or a hypospadic urethra (when the opening of theurethra is on the underside of the penis) will usually work just fine, andsurgery to move or reconstruct the urinary opening does not make any
improvements. Nor does an infant need a “functional” vagina, forexample—whereas an adolescent may have an opinion as to whether
one would be necessary. “Normal” anatomy—especially for purposes ofsexual function—does not need to be, and should not be, addressed inchildhood before the individual can assess which functional and/or
cosmetic considerations are most important to them.
STATEMENT:Intersex people favor early surgery.

THE TRUTH:
This is simply untrue. The largest intersex support group in
the United States, the AIS-DSD Support Group, condemns early surgery,as does every major intersex organization in the world led by and forintersex individuals.​ ​ If someone says there is research to support thisstatement, ask for the studies—those “concluding” that intersex people
favor early timing of surgeries are not representative because: 1) the
sample sizes are very small; 2) respondents are often not given theoption to indicate “no surgery” as a preference, only an age range for(inevitable) surgery; 3) respondents are not made aware of the risks ofsurgery before answering; and 4) respondents have all had surgery
themselves, usually before they were old enough to consent.
Proponents of early surgery sometimes claim that there is a “silent
majority” of intersex people who support this practice or who were glad
to have had their own surgeries performed before they could consent,
but the argument that intersex advocates are just an angry minority isused to belittle the patient community and justify ignoring our voices.

STATEMENT:

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Early surgery has proven psychological benefits.

THE TRUTH:
Like the last statement, this is simply untrue. Ask for thestudies, which have shown demonstrable psychological harm resulting
from early surgeries—including PTSD, depression, shame and low
self-esteem, an increased risk of suicide, and trauma of the same natureas that which results from childhood sexual abuse. Most who support
surgery on psychological grounds do not take into account changing
levels of acceptance for different types of bodies. In addition, often they
start from the original position that genital difference is inherently
harmful, without any recognition that harmful psychological outcomesmay be a result of the way caregivers interacted with the difference. In
fact, recent studies indicate intersex children who did not undergo
surgery are doing just fine! With supportive and accepting caregivers
and families, these children thrive without surgery.
STATEMENT:Society isn’t ready for a non-binary or third gender, andit’s not right to force children to live with a different
gender.

THE TRUTH:
This issue has nothing to do with forcing children to livewith a non-normative gender. It’s about ensuring no one is forced toundergo a deeply harmful surgery they didn’t ask for. An intersex childcan be raised male or female just like anyone else, and they don’t needsurgery in infancy to be a boy or a girl. Intersex advocates are notsuggesting that all intersex children be assigned a third or non-binary
gender, just that they be free from harmful surgeries like clitoral
reductions and gonadectomies.
STATEMENT:

Early surgical intervention is necessary to protect
children from bullying in the locker room.

THE TRUTH:
Unlike in the past, most children do not have mandatory
nudity in any childhood activity—in fact, mandatory nudity is actively
prohibited in the majority of situations. interACT’s experience working
with schools, hospitals, and in other institutional settings indicates thatthe appropriate response to issues regarding bodily difference (for bothintersex children and their non-intersex peers) is thoughtful
acceptance and modeling from caregivers rather than mandatory
surgery. In over a decade of experience as legal advocates for intersex
children, we have encountered very few instances of bullying, none ofwhich could not be addressed by thoughtful adult intervention. Issues

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with bullying should be resolved by addressing the harassing behavior,
not through pre-emptive, irreversible surgery.
STATEMENT:We need more data before we can stop performing
early surgeries. O​ r: ​We don’t know what would happen
to intersex children who grow up without surgery.

THE TRUTH:
This is the exact opposite of the evidence-based approachtaken elsewhere in medicine. It is not scientific to ​default​ to risky
procedures without proven benefits and then demand evidence ofharm in order to stop performing them; good science would look for
affirmative evidence of benefit b​ efore ​establishing a treatment
paradigm. Some physicians will claim that allowing intersex children togrow up without surgery is “experimental,” but the real experiments
are the early surgeries still being carried out without knowledge of theirlong-term outcomes or proof that they serve a therapeutic purpose.
Moreover, people born intersex grew up without surgery for all of
human history before the mid-twentieth century—and the limited
studies of non-operated intersex children today show that they are
growing up healthy and well-adjusted. Supporters of early surgery havebeen claiming for decades that we cannot alter our approach to caring
for intersex children without first having more data in hand, but duringthat time, they have failed to produce it—and the truth is that the kindof data that will satisfy them will never exist because conducting agold-standard double-blind clinical trial would be ethically impossible.

Would you like to provide feedback on this document or your own experience?
Please contact us! Email i​ nfo@interactadvocates.org​.

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