By SUSAN ADELMAN, MD
I am a pediatric surgeon. I have operated on babies who were born without a functional anal orifice, but I have never operated on babies who were born with what were called ambiguous genitalia. It just never came up in my practice. These were specialized procedures done by surgeons with advanced training and experience in such delicate matters.
With that caveat, let me weigh in on the subject of surgery designed to transition a child from his or her biological gender to the opposite gender. When I was in practice, a request for this type of surgery primarily came up in the case of babies with ambiguous genitalia that did not fit their genotype properly, usually because of hormonal abnormalities. This was more than 50 years ago, when most young surgeons were taught that, in the case of feminized or partially feminized genitalia, since it was impossible to create a functioning penis, it was more prudent to remodel the perineum by creating clearly feminine looking external genitalia. So that is what they did. Sadly, some of these children were actually biologic males and later felt themselves to be male as they grew up—a potential psychologic, anatomic and physiologic tragedy. It must be pointed out, however, that those doctors were doing their best at the time.
The scenario described above is a different matter from operating to reconfigure children who are born with normal genitalia that conform to their genetic sex. In our brave new world, these children may be diagnosed with “gender dysphoria” and promptly encouraged to transition to the opposite sex. In the case of a biological girl, first the breasts usually will be removed. If this girl ever plans to have a child, breast-feeding will be impossible. If she goes on to what is called “bottom surgery,” she will need several staged operations to create an organ that has the appearance of a penis, though the functionality of this organ is not equivalent. Specifically, it will require a penile implant later on.
The biologic girl with ambiguous genitalia who is born without a vagina and needs one to be surgically created will require daily dilations of the newly created vagina, or it will shrink. This is similar to what we prescribe for babies with one form of imperforate anus. The mother may need to do daily anal dilations for many months.
This also is what happens with biologic boys who wish to transition and who undergo bottom surgery to create a vagina. In this case, they will have to perform dilations too; inserting a dilator into the neo-vagina every day and leaving it in long enough to properly dilate the orifice. This is painful, and it may take up to two hours a day. Sometimes this routine is required for a year or more, after which dilations must continue at least weekly. Still, the vagina may not be of adequate size or depth, and intercourse later on may be painful.
The neovagina is created by using the tissue of the penis, and we do not have extensive data yet on the long-term effect on urination, urinary tract infections or obstructions. Still, I would be concerned. And the testes are removed, so these children will be perpetual patients of the endocrine clinic, on hormonal maintenance for life. Note that feminizing hormones may cause deep vein thromboses, infertility, high blood pressure, type two diabetes, stroke, and changes in the skeleton. Masculinizing hormones also cause numerous irreversible changes, like hair loss on the scalp, and increased body hair. If a biologic girl who is trans wants to have a baby, she must discontinue the hormones for a period of time, and hope that her normal female hormones will kick in. A biologic male cannot have a baby.
We hear of many young people who complain of feeling uncomfortable in their own bodies and who are quickly rushed into a life of hormone treatments and surgery to remove their normal sexual organs, only to regret it bitterly later on. I suspect that nobody told them in the first place what to expect from this profound transition. I suspect that some of the doctors are seeking money, fame, or a surgical challenge, so they do not give the child enough time to reconsider the request for this drastic treatment. I suspect that many of these children never told their parents or any other responsible adult who loves them about their plans, seeing it as an adventure, exciting, or a cure for their psychological problems. I suspect that many of these children have ruined their lives, and do not know it. I suspect they have not seen statistics that show the elevated risk of suicide. In one Danish study, 23-24% of transgender patients attempted suicide, compared with 2-4% of the controls.
We owe it to our youth to publicize the actual effects of transitioning. In responsible institutions, for dramatic interventions such as assisted suicide, there are protocols, required waiting periods, psychological evaluations, and support for the family. For organ transplants, there also are protocols. In experimental treatment for cancer, protocols must be reviewed by an institutional review board. Where are the protocols to review and approve (or disapprove) of surgery when a child is about to completely upend their entire life? Is such a decision not just as important?