Intersexed states: Diagnosis and management

The major revisions the present authors use in their management strategy relate to (1) the recommendation that early genital surgery not be considered mandatory; (2) the appreciation of the impact of prenatal androgen on the developing CNS; (3) the view that adult social function and sexual fulfillment form the primary goals of treatment; (4) the fixed concept of male or female as denoting an agreement among the gender identity, gender role, and sexual orientation should be abandoned and should not be incorporated as a treatment goal or be identified as a measure of success; and (5) the size of the phallus (clitoris or penis) should be considered to be of little importance in the assessment of the intersexed child. In addition to these changes, these authors believe that it is implicit that parents and, as appropriate, the patient have an active role in medical decision making. An initial review and repeated discussions about sexual differentiation and the psychologic domains of gender are paramount to encouraging a durable openness to nontraditional outcomes. Psychologic assessment and follow-up are critical and should be encouraged at all levels. Parents should receive full disclosure so they can help to determine how and when this information can be shared with their child. Parents may need to be reminded that withholding medical information has been cited as one of the most traumatic and damaging aspects of our previous management approach. Finally, we all need to be reminded that there is much that we do not and may never understand about gender. In the final analysis, the cost of understanding this complex problem may be the courage to ask the question "exactly what is gender?" again and again.