MULTIPLE SURGERIES

The statistics tell the story. Although the medical literature exudes confidence about the feasibility of genital makeovers, the procedures are complex and risky. From 30 to 80 percent of children receiving genital surgery undergo more than one operation. It is not uncommon for a child to endure from three to five such procedures. One review of vaginoplasties done at Johns Hopkins University Hospital between 1970 and 1990 found that twenty-two out of twenty-eight (78.5 percent) of girls with early vaginoplasties required further surgery. Of these, seventeen had already had two surgeries, and five had al­ready had three.44 Another study reported that achieving successful clitoral recessions ‘‘required a second procedure in a number of children, a third in several patients and a glansplasty in others.’’ (Glansplasty involves cutting and reshaping the phallic tip, or glans.) They also reported multiple operations following initial early vaginoplasties.45,46

There are fairly good data on vaginoplasty, one of the more common sur­geries performed on intersexuals. Laurent and I summarized the information from 314 patients and offer it in table 4.2. The table suggests the spotty nature of medical evaluation. Researchers gave specific criteria for evaluating an op­eration’s success for only 218 patients. For adults (about 220 patients), one standard criterion was the ability to have vaginal intercourse. What emerges from these studies is that even on their own terms, these surgeries are rarely successful and often risky. First, there are relatively high frequencies of post­operative complications leading to additional surgeries. At times the multiple surgeries cause significant scarring. Second, several authors emphasize the need for psychological reinforcement to allow patients to accept the opera­tion. Third, overall success rates can be very disappointing. One study found that although out of eighty patients, 65 percent had ‘‘satisfactory’’ vaginal openings, 23 percent of these didn’t have sexual intercourse.47 When initial surgeries did not succeed, many patients refused additional operations. Thus, in those studies of vaginoplasty for which evaluation of surgical success in­cludes clear criteria and reporting, the surgery has a high failure rate.

Studies of hypospadias surgery reveal good news, bad news, and news of uncertain valence. The good news is that adult men who have undergone hy­pospadias surgery reached important sexual milestones—for example, age of first intercourse—at the same age as men in control groups (who had under­gone inguinal, but not genital, surgery as children). Nor did they differ from control groups in sexual behavior or functioning. The bad news is that these men were more timid about seeking sexual contact, possibly because they had more negative feelings about their genital appearance. Furthermore, the greater the number of operations men had, the higher their level of sexual inhibition.48 Surgery was least successful for men with severe hypospadias, who could often have normal erections but found that problems such as spray­ing during urination and ejaculation persisted.49

And the news of uncertain valence? It all depends on whether you think strict adherence to prescribed gender role signifies psychological health. One study, for example, found that boys who had been hospitalized more often for hypospadias-related problems showed higher levels of ‘‘cross-gender’’ behav­ior.50 For intersex management teams, such as one that aims explicitly ‘‘to prevent the development of cross-gender identification in children born with. . . ambiguous genitalia,’’ such results might signify failure.51 On the other hand, practitioners have found that even when they follow Money’s manage­ment principles to the T, as many as 13 percent of all intersex kids—not just boys with hypospadias—end up straying from the treatment’s strict gender demands. This distresses psychologists who adhere to the two-party system.52 But to those of us who believe gender is quite varied anyway, gender variability among intersexual children does not constitute bad news.

table 4.2 Evaluation of Vaginoplasty
# OF AGE AT AGE AT SUBJECTS SURGERY EVALUATION CRITERIA FOR SUCCESS RESULTS COMMENTS SOURCE
“Satisfactory” (no stated crite­ria)	Says clitorectomy desirable a with advanced degree of mascu — linization
7
Infants Not given	Not given
< і yr. to >16 >2 yrs.	• Initial surgery: 34% success • Success after 3 procedures: 62%	Significant patient failure to b follow through on surgical op­tions; higher success rates with older patients
42
Comfortable vaginal penetration
23
Notgiven 13—37 yrs.
23
Average Notgiven 1.84-3.3 yrs.

Questionnaires re­porting on sexual ac­tivity, marital status

Suggests greater emphasis on ad — e equate surgical correction and “greater use of psychoendo — crine services… to allow the patients to accept vaginoplasty”

(p. 182)

Discusses pros and cons of vari — f ous vaginoplasty techniques; does not comment on best age for the surgery, but apparently performed on infants

• Lack of success “discouraging” g (p. 601)

• “as a rule the introitus that has been revised early undergoes scarring” (p. 601)

• “it is unwise to attempt introi — tal reconstruction until after puberty” (p. 601)

(continued)

TABLE 4.2 (Continued)

# OF SUBJECTS AGE AT SURGERY AGE AT EVALUATION CRITERIA FOR SUCCESS RESULTS COMMENTS SOURCE 45 3 to > 15 yrs. Not stated Position of the poste­rior border of the vaginal opening; sup­pleness of the sutures and lack of inflamma­tion and stenosis; quality of the vaginal opening; absence of hypertrophy of sur­rounding muscles • 16/45 cases required additional operations after puberty • 6/12 favorable cases said they had satisfactory sexual inter­course Corrective surgery has partly reached its goals in enabling sex reassignment at an early age h 28 3 wks. to 5 yrs. 18—25 yrs. Successful vaginal pen­etration • 6/28 required only 1 surgery • 22/28 required 3—4 surgeries Discusses anatomical factors leading to need for multiple sur­geries, but continues to favor early surgery i 23 Not given :4-38 yrs. Penetration without pain or bleeding; orgasm • With postsurgical dilation, 7/8 satisfactory • without dilation, 4/8 unsatis­factory • 7 had no sexual activity Concludes that childhood vagi­noplasty followed by adult dila­tion produces good results; also presents data on clitorectomy vs. clitoroplasty j

38 All but i Not stated between 13 and 30 yrs. Lubrication; vaginal • Lack of vaginal lubrication: k length or diameter; 6/38 fertility; lack of psy — • vaginal size too small: 3/38 chological problems • infertile: 10/38 • psychological problems: 3/38 • lack of counseling: 12/38 • of 23 sexually active, 18 had satisfactory intercourse a. HendrenandCrawford 1969. b. Azzizetal. 1986. c. Heckerand McGuire 1977. d. Allenetal. 1982. e. Mulaikaletal. 1987. f. Newmanetal. 1992a. g. Sotiropoulos et al. 1976. h. Nihoul-Fekete 1981; Nihoul-Fekete et al. 1982. i. Bailezetal. 1992. j. Costa etal. 1997. k. Fliegner 1996