Intersex Activists in Israel: Their Achievements and the Obstacles They Face.

This article focuses on the dynamic between the medical policy on intersex bodies and intersex activists in Israel. Recently, in many countries changes have taken place in medical guidelines regarding intersex patients and laws that regulate medical practices and prohibit irreversible surgeries for intersex babies for cosmetic reasons and without the patient's consent. In Israel, intersex activists are limited by several factors. On the one hand, they are influenced by the achievements of intersex activism around the world but on the other, the pathologizing medical discourse and socio-medical practices, which include early diagnosis, early irreversible surgeries, and secrecy surrounding intersexed bodies, present obstacles to achieving bodily autonomy for intersex individuals and social recognition of different sex development. Nevertheless, intersex activists are attempting to find different social and media spaces in which to achieve public acknowledgement and future bodily autonomy for intersexed people and seeking medical professionals' cooperation. Recently, the Israeli Ministry of Health published a new circular for intersex/DSD patients, and while it does not clearly forbid irreversible surgeries, it provides information about the complexities of intersex people and their experience.

Management of intersex newborns: Legal and ethical developments.

Countries worldwide are increasingly expanding male/female binary sex classifications to recognize a third status. Intersex newborns may be included in this third category on birth certification. Parents, families, and communities require counselling and education to accommodate intersex newborns without stigma or discrimination. Whatever its biological or genetic origin, intersex status is a natural if relatively uncommon condition (one in 1500-2000 live births) that distinguishes sex from gender. The tendency of societies to recognize only male and female genders at birth has resulted in intersex children being subjected to invasive surgery and related, sometimes lifelong, medication to confirm them as male or female. On gaining maturity, some are severely distressed and resentful that early gender assignment was mistaken, particularly when excision of testes to enforce femininity or of ovaries to enforce masculinity has denied them procreative capacity. Emerging principles support postponement of such interventions until intersex individuals can make a gender choice for themselves.

Reconstructive surgery of the sulcus of glans penis for balanopreputial adhesion due to lichen sclerosus. Our experience and medicolegal implications.

AIM: Our exeperience with the reconstructive surgery of the adhesion of the glans with the preputial skin due to lichen sclerosus. MATERIAL OF STUDY: Twentyeight patients (mean age, 44 years; range, 28-69) underwent reshaping of the balanopreputial sulcus at our institution. All patients presented with trapped penis resulting from adhesion at the sulcus of glans due to Lichen Sclerosus. The procedure entailed separating the coronal adhesion along its entire length with the use of a blunttipped forceps, then reshaping the balanopreputial sulcus. Though simple, the maneuver is delicate and requires scrupulous attention to the ventral aspect to avoid damaging the urethra. The adhesion is removed circumferentially around the glans by means of electrobistoury. RESULTS: The duration of the follow-up period was 24 months. All patients stated they were satisfied with the cosmetic results and functional outcome. Recurrence of the condition occurred in 7% of the patients and was treated medically; recurrence of adhesion occurred in 2% of the patients and was treated with repeat surgery. DISCUSSION: The indication for medical therapy in early LS is a selective criterion restricted to less severe cases; otherwise, the physician may be held responsible for treatment failure, justified claims for reimbursement, disease progression and the decidedly greater damage that may ensue. Such consequences can be averted when assessment is based on recent scientific evidence and the approach to treatment is appropriate in terms of efficacy and effectiveness. Surgical management is definitive and restores normal penile anatomy and function, including sexual and urinary function, thus enabling the patient to regain sexual confidence CONCLUSIONS: Lichen sclerosus et atrophicus is a rare disease, however, its management is not devoid of medicolegal considerations. The etiopathogenesis of the disease is unknown but progression to carcinoma of the penis has been reported in untreated cases. Consequently, timely diagnosis holds medicolegal relevance for averting delayed initiation of treatment. In cases of balanopreputial adhesion with disappearance of the sulcus of glans, we proceed with lysis and reshaping of the sulcus by means of a simple technique we have developed. The technique involves separating the coronal adhesion circumferentially around the glans using a blunt-tipped forceps, then reshaping the balanopreputial sulcus. Though very simple, the procedure is also delicate as the surgeon must be careful not to damage the urethra beneath the ventral surface.

Lessons from the past: directions for the future. Do new marketed surgical procedures and grafts produce ethical, personal liability, and legal concerns for physicians?

New procedures and materials for incontinence and prolapse are proliferating rapidly. Surgical procedures were developed by physicians and carried their names, but over the last 15 years, these procedures are developed by industry and bear the trade names of the companies selling the kits needed to perform them. The Food and Drug Administration (FDA) approves devices, not procedures, and does not require submission of efficacy or adverse-event data to gain this approval by the 510-K process. Evidence-based medicine is lacking in the performance of these procedures that may be considered experimental by an insurance company or malpractice carrier with denial of payment or coverage. Physicians and hospitals are exposing themselves to financial, legal, and ethical risks when performing or allowing such procedures to be performed. Informed consent from the patient cannot be obtained. We must not confuse medical marketing with evidence-based medicine.

Ethics and the proposed treatment for a 13-year-old with atypical gender identity.

The case of a 13-year-old girl given permission by the Family Court of Australia to begin a sex-change process involves complex issues. Nevertheless, the ethical justification for the decision is not complicated. In this case, it can be argued that the net benefit eclipses concerns about competence, autonomy and the appropriateness of the intervention. The debate this case generated in the media reminds us that one of the essential tasks in ethics debates is to get our facts straight.

[Based on the first legal sex change in Spain]. / A propósito del primer cambio de sexo legal en España.

The following study describes and analyzes the various factors that contributed, according to the author, to making Malaga, (in the south of Spain), the first Spanish city to carry out the first legal sex change in the late seventies. It must be stressed that acknowledgement of this new syndrome, i.e. transsexualism, received great interest from the medical setting in Malaga (notably the official College of Medicine and the Department of Psychiatry in the Universiy of Malaga), followed by the media as a whole. On the other hand, the person who was biologically a man asking to have his sex changed in the registry, constituted a prototype of the syndrome, complying entirely with all the characteristics that defined transsexualism. And, lastly, those who intervened in this legal process, (lawyer, judge and magistrate), were shown to be profoundly human in the face of this medical and legal enigma. The legal decision assumed the predominance of gender (experiences, behavior) over biological elements (chromosomes, gonads, secondary sexual characteristics), considering the previous gender as a mistake which, therefore, would be rectified by it.