Gender Re-assignment at 17 Medical, Ethical, Religious and Cultural Dilemma!

To The Editor: Gender re-assignment after attainment of puberty is a challenging exercise. The problem is further compounded in places with limited diagnostic and counseling facilities. We report on a teenager who was raised as a boy until he started to have regular menstruation. The difficulties encountered in the management of this case are highlighted. Case report A 17 year old male student was referred to the Federal Medical Centre Yola by his school teacher and stepfather because of breast enlargement and periodic perineum bleeding associated with school absence. The Teacher confirmed the story and noticed that the student had been walking with a stoop in an effort to hide the enlarged breasts. The patient first noticed the breasts enlargement at the age of 13 and a year later started to have a monthly vaginal bleeding for 4 – 6 days. The patient was given a female name at birth, however at the age of two years the family thought that the child had good sized " phallus ". The child was taken to a local hospital where the family was told that the gender cannot be assigned until the child is older and therefore he was given a male name and kept company with the same gender. With development of female secondary sexual characteristics around the time of puberty, the parents were convinced that the child had been assigned the wrong gender and therefore they sought medical advice. On examination the patient was depressed and dressed in male attire but had female fat distribution. The growth parameters were normal with height of 163 cm and weight of 58kg. Pubertal assessment showed breast development & pubic hair tanner stage IV. Genital examination revealed a phallus of 6cm with redundant labia majora. The labia minora was almost fused in the midline, partially occluding the vaginal opening. There was also a reducible right inguinal hernia. Rectal examination indicated the presence of a uterus. Further investigations revealed normal electrolytes and total testosterone. There were no facilities to do 17 hydroxyprogestrone (17 OH-P), cortisol, ACTH or chromosomal karyotype however buccal smear was positive for Barr body indicating the presence of two X chromosome. Abdominal ultrasound scan showed normal looking uterus. Both ovaries were visualized and appeared normal with no mass in the suprarenal area. A laparoscopy confirmed the presence of female internal genitalia with normal looking ovaries. A clinical diagnosis of simple virilizing congenital …