RCH Paediatric Surgeon's Paper under the Knife

The AISSGA has for some time followed the progress of a long term follow up study being conducted by the Royal Children's Hospital (RCH) Melbourne, the intention of which is to examine a number of treatment practices to see if they are appropriate. Amongst the practices being examined is the appropriateness of surgical reinforcement of gender assigned to a child born with an intersex condition. This is a practice that has drawn much criticism from patient groups and some medical professionals and this is one of the reasons the RCH Melbourne is conducting their study. Some medical professionals still consider surgical reinforcement of gender assignment is necessary for the well being of both the affected infant and their parents for a number of social reasons.

In a paper titled "Androgen Imprinting of the Brain in Animal Models and Humans With Intersex Disorders: Review and Recommendations" written by Zoltan Hrabovszky and John Hutson of the Surgical Department, Royal Children's Hospital, Melbourne, the practice of surgically reinforcing assignment of gender to children with intersex conditions is defended on the basis that previous unsuccessful outcomes were because of miss-timed surgery. Hrabovszky and Hutson put forward a hypothesis that male gender identity forms largely as a result of a peak in testosterone production levels that occurs following birth and that to raise certain chromosomally XY infants successfully as female surgery must occur prior to this peak of testosterone production. Their hypothesis is said to be supported by results of studies using animals and certain observations of groups of patients with intersex conditions or exposure to atypical hormone levels.

Studies conducted on various animal subjects, support the hypothesis that the same hormones responsible for physical sex differentiation are also responsible for certain male or female typical sex behaviours. In some studies researchers have even been able to identify the specific time frame of development of the animal during which behaviours can be influenced in this way. The same cannot be said of studies involving human subjects. Whilst some studies involving human subjects suggest that exposure to androgens can influence the behaviour of chromosomally XX infants so that they exhibit behaviours more usually associated with males, there are no studies that suggest early removal of testes will prevent development of a male gender identity or that retaining them will guarantee formation of a male gender identity. There are members of the AISSGA that prove exceptions to both of these rules and the unpredictable nature of the level of response to androgens in conditions such as PAIS is always going to mean this is the case.

Hrabovszky and Hutson state that there is strong evidence gender identity is linked to genital appearance and that "normalising" surgery is a necessary both for acceptance of an assigned gender by both the infant with the intersex condition and their parents and for proper social adjustment. Nowhere in their paper do they support this assertion with any empirical evidence. Since there have been very few recorded incidences of children with intersex conditions where such surgical reinforcement has not taken place early in the infants life, it would be very difficult to support such claims especially in the context of "Western" society in which most such surgeries take place.

Hrabovszky and Hutson also comment about the need for surgery in cases where there is a risk of cancer or other physical medical problems, such as the removal of gonads in cases of CAIS. Performing surgery where there is a genuinely established need for the physical well being of an infant is really a different issue, as no patient advocacy groups nor medical professionals that we are aware of dispute the need for this to occur in such circumstances.

In the view of the AISSGA, the research cited in the Hrabovszky/Hutson paper tends, on balance, to equally support the view that gender identity forms prenatally and that anti-natal removal of testes will have little effect on gender identity. The Hrabovszky/Hutson paper concludes that hormonal imprinting very likely occurs both pre and anti natally but they assert that removal testicular tissue after birth will minimise the effects of the androgens produced on gender identity. While this is quite possibly true, we do not believe they provide sufficient evidence that removal post term is enough to negate or override any prenatal hormonal influence. If their hypothesis is wrong then early removal of testes in the manner suggested will once again mean children having to come to terms with the ramifications of removal of health organs if gender assignments are incorrect. The upshot of this is that once again it is parents and support groups left picking up the pieces of experimental medicine and for us this is too high a price to pay.

For the AISSGA, the Hrabovszky/Hutson paper also raises some other questions of significance. The paper has been authored and published prior to completion of a long term follow up study examining the appropriateness of the very medical practice the paper defends. Not only does the study examine the subject of the paper, the authors work at the hospital conducting it and John Hutson is a member of the study team that has proposed and is involved with conducting the study. It may be that publication of the Hrabovszky/Hutson paper can be defended on the grounds it is the stated opinion of the writers only and not meant to represent the views of the RCH team involved with the follow up study. In our view it would have been more prudent to publish the paper after the study results had been published when stated opinions can be more properly assessed against the results of a study that is current and directly relevant.

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Last update: 22 January, 2014

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