CLITORAL
SURGERY
Catherine
Minto Research Fellow
Department
of Gynaecology, University College London Hospitals.
TYPES
OF CLITORAL SURGERY
There are
three main groups of plastic clitoral procedures:
1.
Clitorectomy or Clitoral Amputation
This operation
simply removes all that can be seen of the clitoris (ie all of the glans
clitoris), and usually involves dissection and partial removal of the corpora.
Often the prepuce and clitoral hood will also be removed or used for
reconstruction elsewhere. It is believed this procedure is now rarely done in
the UK although no data are available.
2.
Clitoral Recession
In
this procedure, none of the clitoral structures are removed, instead the
clitoral structures are dissected out and then folded up and moved in their
entirety, backwards under the symphysis pubis. As in the clitoral reduction
procedure, the bilateral dorsal clitoral nerves maintain their connection to the
clitoral glans. This procedure was found to cause pain on clitoral engorgement
and again it is presumed this procedure is no longer performed.
3.
Clitoral Reduction
In this procedure the glans clitoris is preserved, and the corpora are dissected and partially or totally removed. Most procedures today will identify the two dorsal clitoral nerves and maintain their connection to the clitoral glans. Sometimes the clitoral glans will be reduced in size by wedge excisions, either laterally, ventrally or dorsally.
AIMS
AND BENEFITS OF SURGERY
Once
a female sex of rearing has been determined, current practice is to perform
appropriate surgery to ensure the genitalia are “normal”. The immediate aim
is cosmetic. It is believed that normal looking female genitalia encourage a
stable gender identity whilst reducing stigma and psychological distress thought
to occur in children growing up with ambiguous genitalia. This practice is based
on the work of John Money in the 1950’s and 1960’s. His premise was that
infants are psychosexually neutral until the age of 2 years and that what is
required for a stable normal gender identity is unambiguous genitalia and
unequivocal assurance from parents at to the chosen gender.
There
are no long term data to support this although there is a widely held belief
that feminising genital surgery is “successful” both cosmetically and
functionally. It is however impossible to predict the true gender identity or
sexual preferences of any baby without an Intersex condition and even more
difficult with Intersex children. It is most likely that gender identity has a
multifactorial basis including anatomical, genetic and endocrine factors. The
contribution of genital appearance to gender identity is unknown but men
diagnosed with micropenis in
infancy can remain happy with a male gender identity and have a male sexual role
(Reilly and Woodhouse 1989).
There
are no comparative data as yet published comparing women who have undergone
surgery to women who have not had surgery. In the USA almost all babies with
ambiguous genitalia have undergone genital surgery since the 1950’s. However
in the UK surgeons were initially reluctant to perform feminising surgery and
there is existing a cohort of older patients who have not had genital surgery.
WHAT
IS A LARGE CLITORIS?
There
are standard measurements available for the average clitoris for a baby. However
most clinical assessment of the genitalia is very subjective. The genital
appearance changes dramatically at puberty with the deposition of labial and
pubic fat and the arrival of pubic hair. What may appear as a large clitoris in
a baby may look much less prominent in a teenage or adult. The majority of
paediatric surgeons spend little time examining adult female genitalia and may
misjudge potential clitoral size. There is a huge variation in size and anatomy
of normal female genitalia. The patient herself may be entirely happy with a
larger clitoris than average.
FOLLOW-UP
DATA
While reports
of operative techniques to reduce clitoral size have been numerous, there have
been correspondingly few studies looking at outcomes of these surgical
techniques. Reasons often put forward for this situation are that much of this
surgery is performed on young infants by paediatric urologists and paediatric
surgeons. These clinicians will not follow up these children regularly and will
therefore not see the adult results of their surgery, either cosmetic or
functional. The genitalia and sexual functioning are extremely delicate subjects
that may be inappropriate or difficult for a paediatrician or paediatric surgeon
to discuss with patients.
A literature
review to look for functional outcomes of clitoral surgery has shown three
groups of studies;
1. Small
retrospective cohort studies or case reports performed by the original surgeon,
with vague outcome parameters. These usually concentrate on surgical technique
and most do not assess sexual function in any detail if at all. None of these
studies is well reported, and all are subject to many biases.
2. Objective
neurological assessment
Only one study
has attempted to evaluate objective clitoral sensory innervation after surgery.
Gearhart et al in 1995 performed pudendal evoked potentials in children before
and after clitoral reduction. They used stimulation of the dorsal neurovascular
bundle with unipolar electromyegraphic electrodes at the base of the clitoris
and EMG response recorded at the tip of the clitoris. He demonstrated
preservation of nerve conduction and claimed this may permit normal sexual
function in adulthood. This is an inaccurate method to study sensation as it
measures large myelinated fibres. Clitoral sensory information is carried in
non-myelinated (C fibres) and small
myelinated nerve fibres (Ad) which
can only be assessed by temperature, vibration and light touch. These studies
have not been done. In addition Chase (1996) stated that adult women who had
undergone genitoplasty as children retained normal pudendal evoked potentials
but had impaired sensation and orgasmic response.
3.
Psychosexual function
Two studies
have looked at psychosexual function in detail. Both have been published in
psychology journals and have received little surgical exposure.
a. May et al
(1996) looked at 19 women with congenital adrenal hyperplasia and compared this
with a control group of 17 women with diabetes. Structured interviews were taped
and analysed. The CAH group reported higher levels of penetration difficulties
and a pattern of persistent pain during intercourse. They were less likely to
masturbate and less likely to attain orgasm compared with the diabetic group
(58.3% compared to 88%). The CAH group were doubtful about the success of
surgery and worried about their genital appearance not being normal.
b. Dittman et
al (1992) looked at 34 women with CAH compared to a control group of 14 sisters.
The CAH women were less likely to experience orgasm with masturbation or
intercourse. They were also less likely to be sexually active.
REPEAT
PROCEDURES
Repeat
clitoral reductions are common especially during adolescence. It is likely that
if one procedure interferes with sexual function, then more procedures will do
more harm. Repeat procedures are common in children with CAH with poor control
or compliance.
WHAT
DO THE PATIENTS WANT?
The difficulty
with feminising surgery on babies is that the decision cannot be made by the
patient. All parents want the best for their children and want them to be happy
and “normal”. Most clinicians at present believe normal looking genitalia
are essential and are happy to recommend and advise surgery.
Whilst parents want to feel able to make their own decisions, they look
to the medical profession for guidance. We should be clear for whom we are doing
the surgery i.e. clinicians and parents rather than the baby.
However adult
patients are increasingly expressing dissatisfaction with the outcome of
surgery. There is a growing campaign – especially in the USA – for a
moratorium on feminising genital surgery. This has led to the establishment of
NATFI (North American Taskforce on Intersex) and our current working party.
Some clinicians are also questioning the need for cosmetic genital
surgery (Schober 1998, 1999).
CURRENT
WORK
At UCLH we are
looking at long term follow up in adult Intersex womenincluding those who have
undergone surgery and those who have not. Our study is a retrospective study
comprising a standardised sexual function questionnaire (modified Golombok Rust
Inventory of Sexual Satisfaction (GRISS)), full genital examination and full
review of medical records including operative notes. So far 131 women have
completed the questionnaire and 40 have been examined. Initial results comparing
women with ambiguous genitalia during childhood who underwent surgery to those
who didn’t suggest a high level of sexual dysfunction in both groups. However
the group who had had clitoral surgery were significantly worse off with 26%
unable to achieve orgasm by any means (Minto et al 2001).
We have also reviewed anatomical and cosmetic finding in adolescents
following childhood surgery and have shown that 77% of children will require
further major genital surgery during adolescence and adulthood (Creighton et al
2001).
CONCLUSIONS
1.
Most data comes from women with CAH. There is no data looking at
long-term result of women with other conditions causing virilisation. Research
in all areas of sexual function in Intersex women is very scanty and should be
encouraged.
2.
Clitoral surgery has a detrimental effect on sexual function particularly
on the ability to attain orgasm.
3.
There are little long-term data to confirm or refute the benefit of
“normalising” the genital appearance. Gender development is multifactorial
and impossible to predict
4.
The effect on female children of having severely virilised genitalia
throughout childhood are unknown.
RECOMMENDATIONS.
1.
Consultation with Intersex support
groups. Seek opinions from adult patients who have undergone surgery and parents
of children who have undergone
surgery
2.
All data on effects of sexual function should be discussed with the
parents. The option to decline surgery must be discussed.
3.
Clitoral Surgery should be avoided on mild and moderately virilised
children.
4.
Clitoral surgery on severely virilised children must be carefully
discussed with all involved in the full understanding of effects on future. The
possibility of deferring surgery should be discussed with the parents. The
possible requirement for further revision surgery must be recognised.
REFERENCES
Chase C 1996
Letter of response J Urol 156:1139
Creighton S,
Minto C, Steele S 2001 Cosmetic and
anatomical outcomes following feminizing childhood surgery for ambiguous
genitalia. Presented to N. American Society for Pediatric and Adolescent
Gynaecology 2001. Accepted for publication in the Lancet – publication date
July 2001
Dittman RW,
Kappes ME, Kappes MH, 1992 Sexual behaviour in adolescent and adult females with
congenital adrenal hyperplasia. Psychoneuroendocrinology Vol17 No2/3 pp153-70
Gearhart
JP.,Burnett A.,Owens JH., 1995 Measurement of pudendal evoked potentials during
feminising genitoplasty:technique and applications J Urol 153:486-7
May B.,Boyle
M.,Grant D., 1996 A comparative study of sexual experiences. Journal of Health
Psychology vol 1(4) 479-492
Minto C,
Creighton S, Woodhouse C 2001 Long term sexual function in intersex conditions
with ambiguous genitalia. Presented at British Assosciation of Urological
Surgeons 2001 (submitted for publication).
Money
J.,Hampson JG.,Hampson JL 1955 Hermaphroditism:recommendations concerning
assignment of sex, change of sex and psychologic management. Bull John Hopkins
Hosp 97:284-300
Money
J.,Hampson JG.,Hampson JL., 1957 Imprinting and the establishment of gender
role. Arch.Neurol.Psychiatry 77:333-336
Reilly
J.,Woodhouse C., 1989 Small penis and the male sexual role. J.Urol 142:569-572
Schober JM
1998 Early feminizing genitoplasty or watchful waiting. J. Paedaitr.
Adolesce.Gynecol. 11(3):154-6
Schober J.
1999 Longterm outcomes and changing attitudes to intersexuality. BJU
International 83 Supppl3, 39-50
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