The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study

Summary

Background

The effects on sexual function of surgical removal of parts of the clitoris are unknown. For infants with intersex conditions and ambiguous genitalia being raised female, this surgery is often undertaken in early childhood. Our aim was to assess the effects of surgery on sexual outcome in this population.

Methods

We did a cross-sectional study to which we recruited 39 adults who had intersex conditions with ambiguous genitalia who were living as female from clinical (n=15) and peer-support (n=24) settings. We obtained data by use of a postal questionnaire, incorporating a validated sexual function assessment inventory. We also obtained hospital notes of 36 respondents who did not want to remain anonymous, and did genital examinations of 19 women. We assessed sexual problems in relation to surgical history and compared the results for our population to those of a healthy control group.

Findings

Of the 39 individuals enrolled, 28 had been sexually active and all had sexual difficulties. The 18 women who had undergone clitoral surgery had higher rates of non-sensuality (78%) and of inability to achieve orgasm (39%) than did the ten who had not had surgery (20% [p=0·002] and 0% [p=0·03], respectively).

Interpretation

Sexual function could be compromised by clitoral surgery. Debate on the ethics of the use of this surgery in children should be promoted and further multicentre research is needed to ensure representative samples and comprehensive outcome assessment. Meanwhile, parents and patients who consent to clitoral surgery should be fully informed of the potential risks to sexual function.

Introduction

The prevalence of intersex conditions is estimated at one in 2000 livebirths.¹ Many affected individuals present with ambiguous genitalia in the neonatal period or in childhood. Clitoral surgery for intersex conditions was first promoted in the late 1930s by Hugh Hampton Young, a surgeon at Johns Hopkins University, USA.² Later, psychologists at Johns Hopkins developed an intersex management protocol based on the notion that all infants are gender-neutral at birth, and that if unambiguous sex of rearing and unambiguous genitalia were made congruent in the early years, the desired adult gender identity and partner orientation would ensue.3, 4, 5 The theory of psychosexual neutrality at birth has now been replaced by a model of complex interaction between prenatal and postnatal factors that lead to the development of gender and, later, sexual identity.6, 7, 8, 9 For parents, the realisation that their child has an intersex condition invariably results in emotional distress. In the midst of confusion, they have to decide on their child's sex of rearing with the help of health-care providers. In the USA and most western European societies, a female sex of rearing is the most likely clinical recommendation to parents.¹⁰ Once a decision of female rearing is made, surgery is often undertaken to remove any incongruent gonadal tissue and to feminise the appearance of the genitalia—usually through the removal of parts of the clitoris or phallus to reduce its size.¹¹ This surgery is done because it is thought to result in better psychological outcomes for the child than leaving the genitalia unaltered.12, 13, 14, 15

The practice of feminising genitoplasty has created considerable controversy, and is associated with many ethical dilemas.¹⁰ First, there is no evidence that feminising genital surgery leads to better psychosocial outcomes than leaving the genitalia unaltered.⁸ Second, there is no guarantee that adult gender identity will develop as assigned.7, 9 Finally, future sexual function might be altered by removal of clitoral or phallic tissue. Until the late 1970s or early 1980s, clitorectomy—the removal of both the corpora and the glans—was the usual procedure. With greater acknowledgment of the vital role of the clitoris in female sexual function, clitorectomy is no longer undertaken in the UK. Clitoroplasty, which involves dissection of the clitoral skin and removal of most of the paired clitoral corpora with preservation of the glans and dorsal neurovascular bundle, has become the usual procedure.¹¹

Cosmetic alteration of the clitoris is often assumed to have no great long-term effect on sexual function.12, 13, 14 Previous studies15, 16, 17, 18 have reported paediatric surgical follow up of various cohorts of intersex patients who had undergone genital surgery in infancy, but all had small numbers and most did not assess sexual function in detail. The results of two psychological studies,19, 20 which used standardised assessment of adult sexual function after childhood clitoral surgery, suggest that sexual difficulties are more common for adults with intersex conditions than for the general population, with high rates of anorgasmia in intersex women.

Our aim was assess the effects of feminising intersex surgery on adult sexual function in individuals with ambiguous genitalia.