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.

Elena Céspedes. La asombrosa historia de una mujer que ejerció de cirujana como varón / Elena Céspedes. The amazing history of a woman who exercises surgeon as a man

A lo largo de la historia se puede considerar que no han sido muchas las mujeres que han podido ejercer como cirujanas en las diferentes civilizaciones y cuando esto ha sido posible en muchos casos han tenido que hacerlo disfrazadas de nombre. El caso de Elena de Céspedes se puede considerar peculiar en primer lugar por su situación biológica de posible hemafroditismo, a lo que se añade su vida venturera ejerciendo múltiples oficios incluido el de soldado hasta llegar a la de médico cirujana que ejerce como varón. El descubrimiento de esta situación la hace que sea acusada de diferentes delitos y al final juzgada por la Inquisición siendo condenada. Resalta en su personalidad su reconocida inteligencia que la hace progresar desde el punto de vista social desde su inicio como esclava hasta lograr acreditarse como cirujano y cirujano sangrador logrando ejercer el oficio con solvencia y maestría. Se la considera referencia como mujer cirujano en la historia de la medicina

Throughout history it can be considered that there have not been many women who have been able to practice as surgeons in diffe-rent civilizations and when this has been possible in many cases they have had to do it disguised as a name. The case of Elena de Céspedes can be considered peculiar in the first place due to her biological situation of possible hemaphroditism, to which is added her life as a trainee exercising multiple trades, including that of a soldier until she becomes a surgeon practicing as a male. The discovery of this situation causes her to be accused of different crimes and in the end judged by the Inquisition to be condemned. Her personality stands out in her well-known intelligence, which makes her progress from the social point of view from her beginning as a slave to becoming accredited as a bleeding surgeon and surgeon, achieving the job with solvency and mastery. It is considered a reference as a female surgeon in the history of medicine

"En buena medicina". las fuentes médicas del discurso de Céspedes ante la Inquisición / "En buena mediçina". Cespedes' medical sources during their deposition before the Inquisition trial

Uno de los hermafroditas más afamados del siglo XVI español fue Céspedes, un cirujano que trató de persuadir a la Inquisición de que la doble mutación corporal que sufrió era un proceso natural. Céspedes afirmó que la transformación de Elena comenzó cuando dio a luz y fue completada mediante cirugía, pero Eleno volvió a su forma femenina de nuevo en la cárcel, porque un cáncer le forzó a cortarse el pene. En este trabajo estudio el testimonio de Céspedes conocido por la historiografía como el 'discurso de su vida', analizo los argumentos que utilizó para convencer al tribunal de sus transmutaciones consecutivas de acuerdo a su biblioteca e identifico los tres textos médicos en romance en los que se basó

One of the most famous hermaphrodite in Spain’s sixteenth Century was Céspedes, a surgeon who tried to persuade the Inquisition court that the double corporal mutations (s)he suffered were a natural process. Céspedes state that the Elena's transformation started when she gave birth and was completed by surgery, but Eleno became into a female shape again in prison, because a cancer forced him to cut himself the penis. In this paper, I study Céspedes' deposition, known by historiography as the "discourse of her life", I analyze the arguments (s)he used in order to convince the court their consecutive transmutations according their medical library, and I identify the tree vernacular medical texts (s)he based on

Shifting syndromes: Sex chromosome variations and intersex classifications.

The 2006 'Consensus statement on management of intersex disorders' recommended moving to a new classification of intersex variations, framed in terms of 'disorders of sex development' or DSD. Part of the rationale for this change was to move away from associations with gender, and to increase clarity by grounding the classification system in genetics. While the medical community has largely accepted the move, some individuals from intersex activist communities have condemned it. In addition, people both inside and outside the medical community have disagreed about what should be covered by the classification system, in particular whether sex chromosome variations and the related diagnoses of Turner and Klinefelter's syndromes should be included. This article explores initial descriptions of Turner and Klinefelter's syndromes and their subsequent inclusion in intersex classifications, which were increasingly grounded in scientific understandings of sex chromosomes that emerged in the 1950s. The article questions the current drive to stabilize and 'sort out' intersex classifications through a grounding in genetics. Alternative social and historical definitions of intersex - such as those proposed by the intersex activists - have the potential to do more justice to the lived experience of those affected by such classifications and their consequences.

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.

It is more than sex and clothes: Culturally safe services for older lesbian, gay, bisexual, transgender and intersex people.

This paper outlines the development of culturally safe services for older lesbian, gay, bisexual, transgender and intersex people. It draws on a framework for cultural safety, developed in New Zealand which incorporates an understanding of how history, culture and power imbalances influence the relationship between service providers and Maori people. This has been adapted to the needs of older lesbian, gay, bisexual, transgender and intersex Australians.

Anatomía de la monstruosidad: la figura del monstruo como objeto de la Mirada médico-anatómica moderna / Monstrosity's anatomy: the figure of the monster as the object of a modern medical-anatommical look

Este texto plantea un análisis de la sustitución de la categoría médica de monstruo por la de hermafrodita. Para ello, se basa en el desarrollo de la anatomía humana en el siglo XVI y en el estudio de la relación fisiológica de los órganos del cuerpo a partir del XIX. Se supondrá como necesaria la investigación anatómica cartesiana y su reflexión sobre el cuerpo para poder abrir el camino a la mirada fisiológica sobre la vida como preludio de la medicina legal y social (AU)

This paper presents an analysis of the monster category on medical research in the modernity. This analysis is based on the development of human anatomy in the sixteenth century and in the study of the physiological relationship between body and organs in the XIX. The Cartesian anatomical research and the naturalization of monster category will open the way to the physiological view of life as a prelude to legal and social medicine (AU)