and 9 at 1 and 5 minutes, respectively, a newborn was delivered with a birth weight of 6 pounds 5 ounces.

The physical examination was unremarkable, except for complete absence of the penis. The scrotum

appeared normal with bilateral palpable gonads of normal size. A voiding cystourethrogram demonstrated a

normal bladder without uretero-vesical reflux; the contrast study revealed that urine partially emptied into the

rectum and colon. The urethral meatus was positioned at the anterior anal verge. Karyotype was 46 XY. This

is the third child for this couple. They have a 4-year-old boy and a 6-year-old girl.

To which sex should this infant be assigned? Accompanying decisions concern disclosure of information to

patient and family (what should be disclosed about the condition and its treatment and when?); surgery to

have the genitalia match the sex assignment, or alternatively, female genital anatomy (what should be done

and when?); psychological support of the patient and family (who should provide it and what model of care

should be followed?); and involvement of other family members and friends (should they be told, and if so,

what should they be told and when?). J Dev Behav Pediatr 24:115 –119, 2003. Index terms: ambiguous

genitalia, sex differentiation, intersex, biomedical ethics, penile agenesis.

As all intersex situations, that also is a disgusting one.

This challenging case is a rare condition that will not be

encountered by most pediatricians. However, it represents a

dramatic example of other more common conditions

discovered in the newborn period associated with ambiguous

genitalia. Primary care pediatricians are often the first

to recognize the structural abnormalities in the external

genitalia and the first to speak to the parents about the

condition. A knowledge of genetic and endocrinological

principles that modulate fetal sex differentiation is essential

but insufficient to provide comprehensive information to

the parents. The influence of fetal sex hormones on gender

identity and the incorporation of principles of patient rights

and patient autonomy are additional areas of knowledge

required to guide therapeutic decision making.

That last phrase, for me, is the most important, perhaps, in that paper:

The influence of fetal sex hormones on gender identity…. the incorporation of principles of patient rights….. and patient autonomy.

Those 3 aspects, for me, are the most important in all gender dysphorias situations, intersex or any other: remember the hormone action during pregnancy….... respect the patient’s rights and respect the person autonomy.

Understand the first, and recognize the second and the third, that is the way, surely, to understand better all those situations.

But who is the patient? The child, the baby, the intersex or gender dysphoric, AND NOT its family.

A variety of new concepts about newborns with intersex

conditions have surfaced in the medical and bioethical

literature. They reflect recent knowledge about the complexity

of gender identity and gender role, bioethical considerations,

and the influence of patient advocacy groups.

Gender identity and gender role. And the influence of patient advocacy groups.

As you will see, I think the most part of our difficulties start when we mix up gender identity with gender role playing in society, as a point of principle. And all the time, we are mixing them up, in the next 50 years.

Another  note is: why need the patients to have advocacy groups? Surely because they feel as victims of someone, or something. Only someone that thinks he has rights, fight with an advocacy group. And if he has rights, and need to fight, is because someone or something gave-up, in some situation, his rights (pardon me my English. Those things are complex to explain in Portuguese… for me in a foreign language is almost impossible! But I will try)

These recent considerations are of interest to developmentalbehavioral

pediatricians in that they focus on critical aspects

of subsequent developmental outcomes.

Drs. David Sandberg and Tom Mazur are pediatric

psychologists who specialize in the care of children and

adolescents with endocrine disorders. They are members of

a comprehensive clinical management team in pediatric

endocrinology at the Children’s Hospital of Buffalo and the

Departments of Psychiatry and Pediatrics, University at

Buffalo School of Medicine and Biomedical Sciences.

Drs. Sandberg and Mazur are involved in clinical research

on the psychological adaptation of individuals with a

variety of endocrine-related conditions and their families.

Dr. Erica Eugster is a clinical associate professor of

pediatrics in the section of pediatric endocrinology at

the Riley Hospital for Children in Indianapolis, Indiana.

Dr. Jorge Daaboul is an assistant professor of pediatrics in

the Division of Pediatric Endocrinology at the University

of Florida, College of Medicine. Dr. Daaboul has studied

ethical issues that impact the early decision making in

children with intersex conditions.

Martin T. Stein, M.D.

Professor of Pediatrics

University of California San Diego

Children’s Hospital San Diego

San Diego, California

I would like to thank Martin Stein, for that so interesting introduction. So correct, so perfect introduction of the problem.

Don’t be fooled—this rare case has more to teach than you

might think! The infant is born with the extremely rare

condition of penile agenesis (also known as aphallia).

Mortality is high, because of associated urinary and gastrointestinal

tract problems; however, complex forms of these

associations are absent in this particular infant. Although

rare, the case illustrates common challenges in the clinical

care of patients with disorders of sexual differentiation

(‘‘intersex’’), in whom there is discordance among sex

chromosomes, gonads, sex hormones, and phenotypic sex

(internal reproductive structure and external genital appearance).

Thank you Tom for your words here. I like very much that concept of different tissues, different aspects discordance, that generates intersexuality and also all dysphorias. All dysphoria shows a discord, a lack of inner harmony.

Until the mid-1950s, medical management of individuals

with intersex conditions was guided by the belief that an

individual’s ‘‘true sex’’ could be revealed through examination

of internal anatomy. It was assumed that a person’s

identification as male or female would naturally conform to

‘‘true sex.’’

That “True Sex” concept is very important. I think it is more important than we think today. Not as we considered in the past, thinking true was only genital anatomy. That idea to resume sex as genitals, saying that is true, is one of the most difficult concepts in humam mind, because is inside us for millions of years, or almost some cents of thousands of years. My MS sexology dissertation was about it, but unfortunately, it is only in Portuguese. But I think, we need really to find a “true sex”, because each of us has a true sex: male, female or androgynous, but surely, existentially for each of us, it is true.

Based on reports suggesting that this assumption

was incorrect, guidelines were changed, and sex assignment

decisions were based on the principle of ‘‘optimal gender,’’

which considered multiple aspects of outcome, most

prominently potential for complete sexual functioning.3

That “Optimal Gender”, in my philosophical point of view, is a way to non respect the autonomy and the right of each human being to exist, and exist as feels its life and its sex and reality. I prefer we continue looking for the “True sex”, not anymore as a genital condition, but as one existential condition.

I think that constructivist point of view, of social and anthropological construction of gender identity as gender role playing and gender dichotomy as only a cultural and ideological construction, is a very hard reduccionism, reducing the human being as an object (reification), and not recognizing the human rights of all humans as  persons, as a whole, with its autonomy.

This approach, which stood largely uncontested until

recently,

Thank the Heavens, now it is changing!

 is predicated on two assumptions:4 (a) ‘‘gender

identity’’ (i.e., identification of self as either girl/woman or

boy/man) is not firmly established at birth but rather is the

outcome of rearing sex; and (b) stable gender identity and

positive psychological adaptation require that genital

appearance match assigned sex, which often calls for

reconstructive genital surgery.

Tom, those two points of principle, are not “scientifical”, based in research and evidence, but ideological, based in pre-conceptions. Based in Freud’s  & Fliess ideas, in XIX century! Based not in science, but in ideologic points of principle, too!

That is the first big problem of that old point of view: those two ideologic principles. See, all the time, we have philosophical and ideological principles in question, and never true science.

 It is essential to distinguish

between gender identity and other aspects of gender-related

behavior, which may be influenced by prenatal hormones.

This includes ‘‘gender role,’’ which refers to behaviors that

differ in frequency or level between males and females in

this culture and time (such as toy play or maternal interest),

and ‘‘sexual orientation,’’ which refers to sexual arousal to

individuals of the same sex (homosexual), opposite sex

(heterosexual), or both sexes (bisexual).

Here there is a very interesting mistake, also an ideological mistake. And subreptitiously, the developers of those ideas,  introduced more “points of principle”, without any scientifical evidences.

Money’s work, and later also Erhardt  & Meyer-Bahlburg paper (1980-Science), defined as Points of Principle, that the patterns of playing are related to gender role playing, and not to gender identity. History and arqueology shows us, that is not true. In India and Pakistan, in Mohenjo –daro and Mergharth excavations of pre-Vedic cultures, probably Drawidian, they discovered a lot of typical female ornaments for ears  etc.. with more than 8000 years. The same occurred in Egypt, in pre-dynastic Egypt, in Naqada culture, some 7000 years ago. Women, in all cultures, like to feel beautiful and desirable, etc… independent of culture, but dependent of gender identity.

And they established, as another point of principle, gender identity was not related to sexual hormones during gestation, but “gender roles”. That point of principle, is also not scientific, but ideological. That was their definition, but not the reality.And they based that conclusion, in the point of principle that any non human primate or mammal, had a core identity. Primatologists today show chimpanzees and bonobos have surely a core identity.

All gender dysphoric victim shows all the time, during first childhood, its inner tendencies, with its playing patterns. LATER, with not so small age, the family, the others start interfering in that playing patterns, and from gender identity expression, the child starts changing to a gender role expression. A lot of victims show it thru their anamnesis, and explain very well it. And good science is based on evidences, thru the external answer of the patient, and not based in our internal models and ideologies.

So, there are gender identity and gender roles. But surely, the hormones are important for gender identities, and never for gender roles. Gender roles are truly role playing… something socially constructed. Gender identity is inner feeling.

What feels in us?

Our brains!

Our selves are the virtual creation of our brains!

The hormones may act not in society, but in the children’s brains, so they may be important for gender identities and never in gender role playing.

Those papers in the 70’s and 80’s where very distorted ideological papers, and never were based in scientifical evidences, but in the inner ideas of the authors.

They fought against a lot of evidences, from Imperato McGuinley, from Dorner, from Gorsky, from Swaab, etc, using only ideological Points of Principles. Fortunately, now, we are not being so misled by those points of principles.

The clinical approach to disorders of sexual differentiation

(‘‘optimal gender policy’’) has recently been

criticized from several perspectives. First, the notion of

gender ‘‘neutrality’’ at birth has been challenged as a result

of a widely publicized case.5 The individual in this case

has a 46, XY karyotype and was born with normally

formed male genitalia. After a circumcision accident at the

age of 7 months left him without a penis, the child’s

gender was reassigned, but not until 17 months, and the

child was subsequently reared as a girl. This individual

(referred to as ‘‘John/Joan’’) has been studied extensively

as an adult.6 He reports having been uncomfortable as a

girl (‘‘gender dysphoric’’) and, starting at age 14 years,

began to live as a male. He received a mastectomy and

began testosterone replacement therapy in adolescence

followed shortly after by phallic reconstruction. At age 25,

he married and adopted the woman’s children. The gender

dysphoria and ultimate sex reassignment of this individual

is believed by some to have been predictable from

experimental studies in animals in which exposure to

androgens during sensitive periods of early brain development

is associated with male-typical brain and behavioral

development.7

That David Reimer history is very impressive. Surely, happened a scientific manipulation of the results. The patient was all the time disrespected, because the ideas, theories and ideologies were more important than reality. The Points of Principle, were only ideological but not scientifical ones.

 Although animal experimental research has

shown a relation between prenatal androgen exposure and

sex-dimorphic behavior, such studies have not examined

‘‘gender identity’’ per se.8

That is a very important ideological point of principle: Animals don’t have any identity, so they cant have gender identity. That is a philosophical, ideological point of view. That is not science researching and evidence. On the contrary, today, Damasio’s works in neurobiology, and a lot of works in primatology from de Waal (see Bonobo, the forgotten ape, de Waal& Lanting, 1997,  U California Press) and a lot of others (mainly Walraven et al,1995 ; Westergaard & Hyatt, 1994), show all animals, including man, have a “core identity”, and in that core identity, they show they feel male or female, they feel one gender identity. Obviously not as humans, but as someone.

Each animal, each organism, really each closure, organic closure, is a someone and not a something. And  each one, in its own way, feels female or male. That is gender identity. That surely is gender identity in man and other primates, and other mammals.

When the “animal shows its sexual answers thru a lot of situations, as the little child, they are showing and expressing their gender identity, surely. Why not? So, all scientific evidences point that way, and don’t agree with those old ideological Points of Principle.

 The impact of the John/Joan

case for clinical practice is also tempered by the report of

another child with a traumatic amputation of the penis with

considerably different outcome.9

The big difference is, all old idea was accepted as “science”, because David’s results reported by Money and his co workers (those two old books) gave the experimental background for those “points of principle”. During a lot of time, during the sixties, seventies and eighties……but now, when truth appeared, the castle dismantled.

Today what we may say?

Sometimes, perhaps, may be, sex of rearing may be important. But surely we may say, it is not the determining factor to generate gender identity.

All those ideological points of principle dismantled. We need now, to study hard, BASED IN SCIENCE AND EVIDENCES and never more in our ideological points of principle, what is truly important in gender identity determination.

As new “points of principle”, more scientifically based ones, we have now:

1^st: Gender identity is the expression of our brains. We are the virtual construction of a self, from our brains and body. Descartes was not correct (See Damasio’s “Descartes Error” and posterior papers). There is no self, and no gender identity, without a neural brain behind. So, let’s understand our brains, and discover how and when  gender identity is formed in the brain.

2^nd: The gestational hormones circulation, action, and activation, mainly testosterone and its metabolites, play an essential role in that process. We are not sure how it works, but we have a lot of evidences among other animals (Gorsky, Dorner, Swaab, Pfaff, etc), non human primates ( Resko, Bonsall, Michael, Sholl, etc) human cadavers (Dorner, Swaab, Gorsky, McEwen, LeVay, etc) and alive humans (Kawamura, etc), that gestational hormones are very important in the human and other animal’s brains, in systems surely related to gender identity (Newman,2000).

3^rd: As the genital tissues may have conformation problems, including cross gendered problems, as intersex conditions, why not the brains, as another part of the body, could not have the same kind of problems?

4^th: We know, today, thru primates results (Bonsall, Michael, Resko, Roselli, etc), that in our brains and our genitals, the hormone action IS NOT THE SAME! We have a lot of results about that. So, if the processes involved are different, and the agents are also different, why not could have different results, sometimes? Why  a very interesting study in that way never was developed? Why not?

5^th: Another interesting scientifical evidence: who masculinizes the genitals is DHT. Who masculinizes the brain IS NOT DHT, but testosterone. And there may happen a differential activation of the androgen receptor, by DHT and T (Pinsky& Kaufman, Gottliebe, etc). So it is possible (only possible), that sometimes, in some transsexual situations (not necessarily all), could happen a good action of DHT in the genital tissue, but a not so good of T in the brain! No one, up until now, studied that possibility, seriously. I tried to study it in Brazil, but the universities here denied that possibility to me.

Tom I don’t know how is formed the gender identity. Surely, a lot of inputs contribute in that existential formation. But what I am sure is, that formation happens in the brain, mainly during pregnancy (Clark,et al, 1988). After birth…society, families, etc, modulate and limit gender identity expression and living. And all that problem generates a lot of existential problems, for all intersex, transsexuals and all gender dysphorics, that live that kind of discord as its inner reality.

 As an adult, the individual

maintains a female gender identity, although she

exhibits masculine occupational and recreational interests

and a bisexual orientation.

A second challenge to the ‘‘optimal gender’’ policy

comes from intersex individuals themselves, who are angry

about their treatment.10

Here I think it is important to split between the dysphoric or intersexual, and its family and parents. The victim here, the patient here, for me, is the child, never the family. So, what the intersex say? Wait please! Because if you make a mistake, for you will be only statistics, books and papers…. for the family will happens something disgusting and boring…. but for us,the gender dysphorics, intersexual or transsexual, we will live a hell!

A lot of assigned at childhood intersex remain insensible, anorgasmic….truly destroyed. They remain as gender dysphorics (MtF or FtM), and sometimes, even without a gender dysphoria, they have a sexual dysphoria, because they feel assexed people, without pleasure, without  possibilities.

They hide themselves. Here in Brazil, a TV channel asked me to show some intersex and hermaphrodites, to interview them in a talking show. I said them, NO! It is impossible, it would be very aggressive against them! They exist, I have a lot of patients that suffer that kind of sufferings, but they may never be socially exposed that way.

Why?

Because all they need, is respect, and the right to be themselves, in their way of living and suffering. What we may do for them? We may do, what Money don’t did: respect their feelings. Their feelings are more important than their families, than their schools and neighbors, then their relatives, I say, even, for me their feelings are more important than Law. Because our laws, sometimes are very stupid and ignorant, because we are stupid and ignorant. But they may not pay the price of our stupidity and ignorance.

 They object to the fact that they

were either not informed or misinformed about their

condition, they are still unable to obtain accurate information

about their condition and treatment, and they feel

stigmatized and shamed by the secrecy surrounding their

condition and its management. Many also attribute poor

sexual function to damaging genital surgery and repeated

and insensitive genital examinations, both of which were

performed without their consent.

Those are a mix up of feelings, between the victims and their families.

Finally, social constructionists have challenged the entire

enterprise of medical management of intersex cases by

arguing that medical practices are rooted in history,

language, politics, and culture, and therefore are not

universal scientific facts.10 Thus, the ‘‘correction’’ of an

intersexed infant’s genitals is less a medical emergency than

it is the adoption of medical technology to support a cultural

imperative to view the sexes as dichotomous. Supporters of

this point of view contend that such beliefs result in

unnecessary and damaging surgery.

I don’t agree with their ideologic points of view, but I agree with the results. Wait the child manifestation. Assign a “preliminary” sex, a social rearing in one sex, in a very androgynous and light way… the child need to show who he/she is, and if we respect and love and permit it, it will happen…. Because the brain is there…. And it will show the inner reality. Only after a free and express solicitation of the child, I think , a “final sex” may be defined, including genitally. And improve your surgeries, please! To live without erotic and sensual possibilities, surely is too hard! Respect the autonomy of the victims!

How should a decision regarding sex assignment be

reached in the present case? Until recently, most children

with aphallia would receive a female sex assignment.

That surely is the worse decision possible. Why? Because possibly the brain had not the same genital problems, we are not sure.

What I suggest to do today in that aphallia  situation?

Possibly the brain is male. Start rearing, in a light way, as a male. And wait. One day, if we know how to observe the child really, not in front of others, but when alone (the gender dysphoric lives all the time hiding from others – based in that characteristic I propose the development of Gendercare Game-Tests for diagnosis of dysphoria in little children). Playing our game, the child feel alone, and show itself…and we receive electronically the results, thru the web. So, after time or our test (to gain some years), we may decide who he/she is. And ask them, what they would like to be…etc..

Only after that process, until we have a better brain diagnostic, if we will have one one day, we could, respecting the child as a person, with a life and a future, see if we will adapt a surgery or not (good quality surgeries, please!)

Accordingly, the testicles would be removed and genital

surgery performed to create the outward appearance of

female genitalia, that is, labia and clitoris. Surgical

construction of a vagina might be performed at this time

or be postponed until adolescence. A feminizing puberty

(development of breasts and feminine body) would be

achieved through the administration of estrogen therapy

beginning in the early teenage years. It has been thought that

this approach would maximize the individual’s psychological

adaptation, including gender identity, body image, and

sexual function.

That would be a very dangerous situation for the child. And a lot of times, as a lot of other gender dysphorics, with shame and fear, they never will openly admit their sufferings. I am sure, the most part of the “good” feminization solutions that way, are not real, but is an inner torture for the victim. Ashamed, fearing life, parents, and all, they close in themselves, as the gender dysphorics most part of the time do.

 Conversely, delaying or avoiding surgical

construction of female external genitalia would potentially

jeopardize the formation of an unambiguous gender identity

because of the incongruence between gender rearing and

genital appearance.

That is not true. That is a Myth. A myth that now need to be reviewed, as soon as possible.

 An alternative decision might be to rear

this infant as a male (consistent with his gonadal sex)

because prenatal testosterone has presumably ‘‘organized’’

the brain, foreclosing identification as a female. Phalloplasty

might then be considered, although the challenges of

this option are daunting and it has only rarely been

attempted. The option of not attempting to provide the

child with a phallic structure would potentially jeopardize

stable gender identity formation.

A lot od FtM transsexuals live that reality. They are men, they feel they are men, and live as men, and play male gender roles in society. But don’t have male genitals, because the surgeries are not so surely good, and the good ones are so expensive. BUT SURELY THEY ARE MUCH MORE HAPPY LIVING AS MALES WITH PROBLEMS, THAN AS FEMALES. Because they are males, they always were males.

Given the dearth of systematic information on long-term

outcome in individuals with aphallia and other forms

of intersexuality, how should this clinical problem be

resolved? How are the parents to be involved in the

decision? What information do they need to make informed

First we were too impressed by our points of principle, ideological ones. Then we are impressed by medicine principles. Then, by society, and now respecting too much the families. Surely, dialectically we are improving a little. But THE MOST IMPORTANT WE ARE IGNORING: THE CHILD’S RIGHTS. The child as one whole human being, not the part of a family. That is the main idea: respect the human being, as a child. It is not important what is good for our ideas. Or the Law, or society. Nor the family and parents. What is important is the human being, and the baby is a whole, an human being. Let’s start respecting it. How?

We have a lot to do:

1^st: scientifical research of the brains and gender identity, thru fMRI, molecular biology, hormone action and expression, etc.

2^nd: start changing social and law principles: Genitals don’t define sex, nor society and role learning. No one learns to be a boy or a girl, but what someone may learn is to play the female or male gender role, society suggest you would live. So we need to start establishing “preliminary sex assignment”, that later, in intersex and transsexual cases, could be reviewed and corrected.

(some decades ago, I was a horse farmer, also. As a hobby, I had Arab horses, very good champions in Brazil, from Egypt lineage. When a foul had birth, we send to the Stud Book, the “preliminary registration”. Here, obviously the problem is not sex, but lineage. More or less 2 to 3 years later, an expert from the Stud Book analyses the stallion or mare, to see if it  is a true Arab or not. The horse shows who he is , by his characteristics, measures, etc.. If all is ok, we have the final registration document, if not, that animal is not considered a pure breed Arab. And the preliminary registration is changed, and the animal is a “mixed arab”, or even nothing.)

If the arab horses, as the throughbreed  and Andaluzian horses have that right, why not could have that possibility our law to protect our children?

decisions on behalf of their child? Rare as this case is, it has

much to teach us. Questions emerge regardless of whether

the infant is assigned a gender and reared as a boy or as a

girl. (We acknowledge Dr. Sheri Berenbaum’s constructive

comments on a draft of this commentary.)

David E. Sandberg, PH.D.

Pediatric Psychiatry and Psychology

Children’s Hospital of Buffalo

Tom Mazur, Psy.D.

Pediatric Endocrinology

Children’s Hospital of Buffalo

Buffalo, New York

REFERENCES

1. Grumbach M, Conte FA. Disorders of sex differentiation. In: Wilson

JD, Foster D, eds. Williams Textbook of Endocrinology. 9th ed.

Philadelphia, PA: WB Saunders; 1998:1303– 1425.

2. Melton L. New perspectives on the management of intersex. Lancet.

2001;357:2110.

3. Money J. Sex Errors of the Body and Related Syndromes. Baltimore,

MD: Paul H. Brookes Publishing Co.; 1994.

4. Zucker K. Intersexuality and gender identity differentiation. Annu

Rev Sex Res. 1999;10:1– 69.

5. Colapinto J. As Nature Made Him. New York, NY: HarperCollins

Publishers; 2000.

6. Diamond M, Sigmundson HK. Sex reassignment at birth. Long-term

review and clinical implications. Arch Pediatr Adolesc Med. 1997;

151:298– 304.

7. Goy RW, McEwen BS. Sexual Differentiation of the Brain.

Cambridge, MA: MIT Press; 1980.

8. Collaer MA, Hines M. Human behavioral sex differences: a role for

gonadal hormones during early development? Psychol Bull. 1995;

118:55–107.

9. Bradley SJ, Oliver GD, Chernick AB, Zucker KJ. Experiment of

nurture: ablatio penis at 2 months, sex reassignment at 7 months, and

a psychosexual follow-up in young adulthood. Pediatrics.

1998;102:e9.

10. Kessler SJ. Lessons from the Intersexed. New Brunswick, NJ:

Rutgers University Press; 1998.

This case represents one of the most difficult situations

faced by parents and health care professionals involved in

the care of infants born with an intersex condition.

See, all expectation is over health care professionals and family….AND THE VICTIM? The child is not a human being, but only a parent’s property, or a family’s part?

Unlike

many other conditions that result in undervirilization of a

genetic male, the 46, XY infant with isolated aphallia was

presumably exposed to normal levels of male testosterone

during intrauterine life. A major concern revolves around

the effect of prenatal androgen exposure on ‘‘masculinization’’

of the brain and ultimate gender identity.

If all our body parts and tissues may be female or male, and not only the genitals: why not the brain? The brain masculinization, or not, is a reality for all other primates and all mammals studied…. Are we not mammals? Not animals? Not primates? Are we Jupiter’s idea, or created by the Jewish and Christian God? Or by Allah? Or by the African Yoruba Gods? Or by Brahma, Vishnu and Shiva?

What can we learn from the literature regarding sexassignment

and outcomes in similar cases? Congenital

absence of the penis is extremely rare, with fewer than 100

cases reported. Although female sex-reassignment and early

bilateral orchiectomy historically have been considered

standard-of-care for these patients, follow-up studies focus

primarily on success of surgical procedures rather than

psychosexual development and function.1 In the few case

reports of aphallia in which a male gender was assigned,2

limited information is available regarding psychological

adaptation and long-term satisfaction.

I fear those “long term satisfaction surveys”. Money manipulated all the time the “long term satisfaction” of David Reimer. That tendency was not Money’s but is human, our tendency. Our ideas ant theories absorb us in a way, that at the minimun possibility we say, it is confirmed! She is a very helpful female!

But a lot of times, men think their women were also very happy, until the day they flew with the neighbor, or ask for divorce. And vice versa.

So, I don’t believe really in those “studies”, mainly because I know how a gender dysphoric may hide the reality, for dozens of years, and sometimes for life.

Another strategy is to

attempt to extrapolate from similar populations of 46, XY

patients with apparently normal early prenatal testicular

function, such as those with micropenis or traumatic penile

loss. Although there are reports of normal male gender

identity and fulfilling heterosexual activity in such patients,3

female gender role and satisfaction with sex-of-rearing have

also been reported in a small number of individuals.4

Truly, very small amount….and please, remember Imperato MacGinleys data from Costa Rica!

A few sensationalized cases of extreme gender dysphoria

and patient groups advocating a moratorium on early

genital surgery have encouraged the medical community to

recognize the critical need for long-term outcome data on

intersex populations.

For her they were sensationalized, because she was not among them. That sort of disrespect, today, is no more acceptable, please!

 However, the few existing studies of

the claims made by intersex support groups have been

limited by small sample size and selection bias.5

Here she shows her ideological bias.

Therefore,

we find ourselves currently in a situation with far more

questions than answers. How, then, should we begin to

address this challenging case?