The history of surgery in disorders of sexual development.

Disorders of sexual development (DSD) have been documented throughout human history with fascination. Healers of all cultures have struggled to explain, and later correct with surgery, the physical manifestations of DSD. DSD was portrayed in the mythology, legends, and art of the ancient Greeks, Romans, Sumerians, Babylonians, and Egyptians. Techniques of feminizing genitoplasties date to the time of Celsus in the time of Christ. Acceptable operative therapy for feminine phenotypes of DSD came in the 19th and 20th centuries. Masculinizing procedures, inherently more complex than feminizing genitoplasties, initially were variations of procedures for severe forms of hypospadias. Today most total penile reconstruction procedures use reconstructive and microvascular techniques invented in 20th century.

In/visibilia: deslubramentos e silenciamentos dos corpos intersexo / In/visibilia: desubraments and silencing of intersex bodies

Nas últimas décadas, a intersexualidade vem constituindo-se enquanto categoria, marcada por uma nova perspectiva sobre uma conformação corporal que, em si mesma, não é uma novidade. Desse modo, emerge como uma problemática contemporânea, perpassada por questões científicas, políticas e éticas. A hodierna problematização da intersexualidade envolve dinâmicas de visibilidade e invisibilidade, identificáveis na visibilização médica da diferença sexual corporalmente localizada e em sua invisibilização social, enfatizada pelo ativismo intersexo. Partindo do pressuposto que o paradigma do "sexo verdadeiro" biologicamente fundado e visto no corpo é produto da era moderna, o objetivo deste trabalho é compreender como a ambiguidade sexual foi produzida em diferentes contextos históricos como efeito de um conjunto de saberes e práticas que orbitavam em torno da visibilidade corporal da diferença sexual. Para tanto, elaborou-se uma genealogia da visibilidade médica da ambiguidade sexual, inspirada pela obra de Michel Foucault. É um trabalho de cunho teórico, cujas fontes principais são documentos históricos de variadas naturezas, encontrados em bibliotecas virtuais e físicas, em sebos e na internet. Discute-se como a diferença e a ambiguidade sexual eram tornadas visíveis nos corpos em períodos pré-modernos e como passaram a ser vistas com a emergência da biologia e medicina moderna. Conclui-se que a coexistência de dois sexos-gêneros em um mesmo corpo humano deixou de ser uma possibilidade médica e social durante o século XIX. Tal impossibilidade emergiu enquanto efeito produtivo de formações discursivas que interseccionavam a medicina, biologia e zoologia e práticas médicas de normalização dos corpos considerados ambíguos.

As a category, intersexuality has been marked in the last decades by new perspectives on a bodily conformation that, in itself, is not new. Thus, it emerges as a contemporary problematic, permeated by scientific, political, and ethical issues. The current problem of intersexuality involves dynamics of visibility and invisibility, identifiable in the medical visibility of bodily sexual difference and in its social invisibility, emphasized by intersex activism. Based on the assumption that biologically founded "true sex" paradigm is a modern era product, this work aims to understand how sexual ambiguity has been produced in different historical contexts as effect of a set of knowledges and practices that orbited around the bodily visibility of sexual difference. To this end, a genealogy of the medical visibility of sexual ambiguity was built, inspired by Michel Foucault's oeuvre. It is a theoretical work, and main sources are varied historical documents, found in virtual and physical libraries and on the internet. It discusses how sexual difference and ambiguity were made visible in pre-modern times and the shifts brought by biology and modern medicine. Findings indicate that the coexistence of two sex-genders in the same human body was no longer a medical and social possibility by 19th century. This impossibility arose as a productive effect of discursive formations that intersected with medicine, biology and zoology and normalizing medical practices performed in the so-called ambiguous bodies.

Did Bioethics Matter? A History of Autonomy, Consent, and Intersex Genital Surgery.

This article argues that the rise of bioethics in the post-WWII era and the emergence of the legal doctrine of informed consent in the late 1950s should have had a greater impact on patients with intersex traits (atypical sex development) than they did, given their emphasis on respect for autonomy and beneficence toward patients. Instead, these progressive trends collided with a turn in intersex management toward infants, who were unable to provide autonomous consent about their medical care. Patient autonomy took a back seat as parents heeded physicians' advice in an environment even more hierarchical than we know today. Intersex care of both infants and adults continues to need improvement. It remains an open question whether the abstract ideals of bioethics-respect, patient autonomy, and the requirement of informed consent-are alone adequate to secure that improvement, or whether legal actions (or the threat of litigation) or some other reforms will be required to effect such change.

Preserving the reproductive potential of transgender and intersex people.

BACKGROUND: The bodies of some transgender and intersex people have been mutilated and their minds subjected to immense distress. Their gender has often been determined by others. Loss of fertility used to be considered an inevitable consequence of treatment. OBJECTIVE: To review the issue of preserving the reproductive potential of transgender and intersex people. METHODS: A narrative review based on a wide-ranging search of the literature in multiple disciplines. RESULTS: Major technological advances have facilitated reproduction for transgender and intersex people in the last few years. A majority of trans-adults believe that fertility preservation should be offered to them. Deferment of surgery for intersex people is often best practice; gonadectomy in infancy closes off fertility options and determines a gender they may later regret. CONCLUSIONS: Transgender and intersex people should be able to consent to or decline treatment, especially radical surgery, themselves. Preservation of reproductive potential and sexual function must be given a high priority. Treatment by multidisciplinary teams can provide a strong emphasis on mental health and well-being. Detailed information about options, an absence of any coercion and enough time are all needed in order to make complex, life-changing decisions.

Gender and Cortisone: Clinical Practice and Transatlantic Exchange in the Medical Management of Intersex in the 1950s.

This article complicates the history of the standardization of intersex case management developed at the Johns Hopkins Hospital in the 1950s by focusing on clinical practices and logics and the transatlantic circulation of knowledge. Using patient records and published studies, I follow the exchanges between pediatric endocrinologists Lawson Wilkins (Pediatric Endocrinology Clinic, Baltimore) and Andrea Prader (University Children's Hospital, Zürich) on cortisone treatment for children with congenital adrenal hyperplasia (CAH), on psychosexuality and gender role, on choosing and changing the sex of intersex children, and on genital surgery. I argue that a focus on the transatlantic exchanges between these two clinics illuminates a more complex genealogy of modern intersex case management. It also provides insight into how physicians understood their clinical practice and sheds light on the messiness and pragmatic contingencies of what only in retrospect appears to have been a consistent treatment regime.

Fluidity models in ancient Greece and current practices of sex assignment.

Disorders of sexual differentiation such as androgen insensitivity and gonadal dysgenesis can involve an intrinsic fluidity at different levels, from the anatomical and biological to the social (gender) that must be considered in the context of social constraints. Sex assignment models based on George Engel's biopsychosocial aspects model of biology accept fluidity of gender as a central concept and therefore help establish expectations within the uncertainty of sex assignment and anticipate potential changes. The biology underlying the fluidity inherent to these disorders should be presented to parents at diagnosis, an approach that the gender medicine field should embrace as good practice. Greek mythology provides many accepted archetypes of change, and the ancient Greek appreciation of metamorphosis can be used as context with these patients. Our goal is to inform expertise and optimal approaches, knowing that this fluidity may eventually necessitate sex reassignment. Physicians should provide sex assignment education based on different components of sexual differentiation, prepare parents for future hormone-triggered changes in their children, and establish a sex-assignment algorithm.

Erecting Sex: Hermaphrodites and the Medieval Science of Surgery.

This essay focuses on "hermaphrodites" and the emerging profession of surgery in thirteenth- and fourteenth-century Europe. During this period, surgeons made novel claims about their authority to regulate sexual difference by surgically ''correcting" errant sexual anatomies. Their theories about sex, I argue, drew upon both ancient roots and contemporary conflicts to conceptualize sexual difference in ways that influenced Western Europe for centuries thereafter. I argue that a close examination of medieval surgical texts complicates orthodox narratives in the broader history of sex and sexuality: medieval theorists approached sex in sophisticated and varied manners that belie any simple opposition of modern and premodern paradigms. In addition, because surgical treatments of hermaphrodites in the Middle Ages prefigure in many ways the treatment of atypical sex (a condition now called, controversially, intersex or disorders/differences of sex development) in the modern world, I suggest that the writings of medieval surgeons have the potential to provide new perspectives on our current debates about surgery and sexual difference.

Sex on a slide: Antoine Lacassagne and the search for a microscopic definition of masculinity and femininity.

In 1919, the French pathologist and pioneer of radiotherapy of cancer, Antoine Lacassagne, studied the case of a young man of indeterminate sexuality (a condition later named "intersex," and recently renamed, "disorders of sexual development"). Lacassagne's argument that the patient was a "true" hermaphrodite, that is, an individual who possesses at the same time male and female sexual glands, was grounded exclusively in his study of microscopic preparations. Such preparations were seen as the definitive proof of the "true biological sex" of a given person, seen as a fixed entity. On the other hand, Lacassagne's definition of biological, or rather histological sex, was dissociated from sexuality, sexual orientation and sex/gender identity. In the 1930s, the isolation of sex hormones made it possible to modulate specific sexual traits, thus destabilizing the concept of a fixed biological sex. It did not undermine, however, the central role of histological proofs. Sex on a slide continued to be seen as definitive evidence of the "true" sexual identity of an individual, but from the 1930s this proof was valid only for the time when a given microscopic preparation had been manufactured.

O discurso biomédico e o da construção social na pesquisa sobre intersexualidade / The biomedical discourse and the social construction in research on intersexuality

A intersexualidade se define pela existência de desequilíbrio entre os fatores responsáveis pela determinação do sexo: o indivíduo apresenta caracteres tanto masculinos quanto femininos. A ambiguidade sexual apresenta-se como demarcador da condição de intersexo. Esta revisão de literatura analisou artigos científicos de medicina, psicologia, ciências sociais e direito/ativismo político, acessados através de bancos e portais eletrônicos. As publicações foram analisadas segundo contexto, área/disciplina, tipo de artigo, conteúdo e metodologia do estudo. Os resultados apontaram que os artigos médicos consideraram a intersexualidade como doença crônica, enfatizando as características endocrinológicas e genéticas, efeitos físicos e psicológicos da cirurgia genital. Os artigos de psicologia destacaram aspectos da sexualidade, identidade e orientação sexual. As ciências sociais realizaram uma crítica à visão bipolar do gênero, ressaltando o processo de designação sexual dos intersexuais. Os artigos do campo do direito/ativismo político priorizaram temas como: estigmas sociais, implicações das cirurgias da genitália e mobilização social em prol do direito à saúde. Em relação às metodologias dos estudos, as pesquisas médicas utilizaram predominantemente a abordagem comparativa; os estudos em psicologia utilizaram abordagens qualitativas com entrevistas semi-estruturadas ou questionários; em ciências sociais, os artigos priorizaram pesquisas etnográficas e revisões de literatura; no campo do direito/ativismo político, foram destacadas narrativas e estudos de caso. As narrativas das famílias só foram encontradas em uma publicação, pertencente ao campo da psicologia. Na maioria dos artigos, o conceito de intersexualidade aparece claramente atravessado pelo discurso biomédico. O legado da biomedicina atua diretamente na construção de significados sobre o corpo e gênero.

The intersex is defined by the existence of imbalance between the factors responsible for sex determination: the individual holds both male and female characteristics. The sexual ambiguity presents the path of intersex condition. This literature review examined papers in medicine, psychology, law and social/political activism, accessed through electronic databases and portals. The publications were analyzed according to context, area/discipline, article type, content and methodology of the study. The results showed that the medical articles considered intersexuality as a chronic disease, with emphasis on endocrine and genetic characteristics, physical and psychological effects of genital surgery. Articles of psychology emphasized aspects of sexuality, identity and sexual orientation. Social sciences conducted a critique of the bipolar view of gender, emphasizing the process of designation of sex intersex. The articles of the field of law/political activism prioritized issues such as social stigmas, implications of surgery of the genitalia and social mobilization for the right to health. Regarding the methodology of the studies, medical research has predominantly used a comparative approach, the studies in psychology have used qualitative approaches with semi-structured interviews or questionnaires, social sciences articles prioritized ethnographic research and literature reviews, the field of law/political activism highlighted narratives and case studies. The narratives of families have only been found in a publication, belonging to the field of psychology. In most papers, the concept of intersexuality appears clearly crossed the biomedical discourse. The legacy of biomedicine acts directly on the construction of meanings about the body and gender.

First colored illustration and detailed description of hermaphroditism by a Turkish surgeon, Serefeddin Sabuncuoglu, in the 15th century.

Cerrahiyyetü'l-Haniyye (Imperial Surgery), written by the surgeon Serefeddin Sabuncuoglu in the 15 century, is the first illustrated surgical book in Turkish-Islamic literature containing human figures. Sabuncuoglu had begun a new era by demonstrating for the first time the application of many surgical methods on human beings, with illustrations in the style of miniatures in his handwritten work. This was a first in medical history, and, owing to this property, Sabuncuoglu's book was one of the most important original works of that period. In this study in which we aim to examine Sabuncuoglu's surgical book, in particular with regard to the disease of hermaphroditism, we first demonstrated the historical development of the subject through general sources. From sources concerning Sabuncuoglu, we gathered information on his life and works. Then, examining the information on hermaphroditism in Sabuncuoglu's work, we discussed this information in light of our current knowledge.

Ambiguous bodies and deviant sexualities: hermaphrodites, homosexuality, and surgery in the United States, 1850-1904.

While the necessity of normalizing surgery on intersexed individuals is a topic of ongoing debate in the 21st century, the origins of surgery as a therapeutic practice for ambiguous or unusual genitalia lie in the 19th century. The first report of corrective surgery published in the United States appeared in the American Journal of the Medical Sciences in 1852, but surgery did not immediately replace more traditional social prescriptions designed to fit hermaphrodites into a dimorphic model of human sex. Only after homosexuality became a matter of discussion in American medical journals did the frequency of normalizing surgeries increase. This paper explores the connection between physicians' increased interest in preventing "abnormal" sexual behavior and their insistence that interventionist surgeries were the most appropriate means of treating cases of hermaphroditism.