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Harvard Medical School physicians David MacLaughlin and Patricia Donahoe published review article in the January 22, 2004 issue of New England Journal of Medicine--the same issue in which a paper questioning sex change surgery for genetically and hormonally male intersex children was also published. MacLaughlin and Donahoe are ardent supporters of the surgery-centered medical approach to intersexuality and frequent contributor to medical journals; Donahoe has co-authored one of the most influential textbook chapters on intersex treatment, which endorsed the surgical quick-fix.
Titled "Sex determination and differentiation," the NEJM paper focuses mostly on the genetic and cellular mechanisms for the "problems" of sex differentiation--i.e. causes of intersex conditions. Authors' pro-surgery bias shows up toward the end of the paper, where they discuss the cause and treatment of congenital adrenal hyperplasia (CAH) in genetic females: "The diagnosis can be made in utero, and early maternal dexamethasone therapy can ameliorate the masculinized phenotypes. Surgical reconstruction can be performed in infancy to restore the female phenotype." In conclusion, the paper state: "Our knowledge is expanding regarding the molecular events necessary to initiate the development of the urogenital ridge and to select and sustain further sex differentiation and development of gonads, reproductive ducts, and external genitalia... This knowledge must be incorporated into treatment strategies in order to increase and sustain the function, happiness, and emotional fulfillment of patients with abnormalities of sex differentiation."
The paper is flawless as a summary of molecular mechanisms that contribute to various routes of sex differentiation, but it is not clear how such "knowledge" is improving the patients' subjective sense of quality of life. For the statement about feminizing surgical reconstruction in infancy, the paper cites another article Donahoe herself co-authored to support its recommendation, while neglecting recent evidences that show clear risks of performing such surgeries and the controversy surrounding this practice. And while MacLaughlin and Donahoe seem to hold patients' happiness and emotional fulfillment as important goals for any medical intervention, they do not seem to be interested in how patients themselves feel about the treatment or in giving patients the ability to make an informed decision on their own behalf. Instead, they insist that the scientific knowledge about the molecular basis of sex differentiation is enough to determine the best course of treatment for these patients.
What is perhaps most deceptive about MacLaughlin's and Donahoe's stance in this and many other papers they write is that they completely ignore the fact that there is an increasingly heated controversy over the cosmetic genital surgeries on intersex children, with experts arguing from both sides. Regardless of what they happen to believe about the treatment, it would be dishonest medically or academically to not acknowledge that it is controversial. Further, physicians who endorse and promote surgery-based treatment for intersex have the ethical obligation to respond to criticisms from adults who went through the procedure and to explain why intersex children should continue to be treated the same way despite these criticisms.
Failure to do so is a sign of weakness of their position.
Source:
MacLaughlin DT, Donahoe PK (2004). "Mechanisms of disease: Sex determination and differentiation." The New England Journal of Medicine. 350:367-78.
Posted by Emi on Jan 30, 2004