Parental choice on normalising cosmetic genital surgery.

About 1 in 2000 children are born with genitalia considered atypical enough to prompt medical investigation. Underlying causes include complex genetic and hormonal conditions as well as unexplained anatomical anomalies such as hypospadias. Paediatricians have previously stated that the determining factor in deciding to raise a child as a boy is the “size of the phallus.” 2 Newborn penile size charts were used in the 1960s, and any child with a penis of stretched length less than 2.5 cmwas likely to be assigned female regardless of the underlying diagnosis; feminising genital surgery usually followed.Gender assignment has become less simplistic but normalising surgery remains common. As a result, little is known about the physical, psychological, social, and sexual effects of untreated atypical genitalia associated with different diagnoses. It has been impossible to determine to what extent difficulties reported by adults are caused by the anatomical difference, other aspects of the diagnosis, the imperfect results of surgery, poor psychological care, or a combination of these factors. Paediatricians’ confidence in the ability to construct genital anatomies to meet cultural expectations of appearance and function has not been borne out. The intended outcomes of these interventions can be known only when individuals reach puberty and adulthood, and reliable longitudinal research does not exist. Persistent concerns from adults who have had surgery in childhood have prompted research with adolescents and adults. In a landmark study with 44 adolescent girls born with atypical genitalia, despite multiple feminising genitoplasties in childhood, almost all participants required further surgery to facilitate menstrual flow, vaginal intercourse, or both. Subsequent research has identified increased difficulty with orgasm among women who had had clitoral surgery and diminished genital sensitivity specific to the site of surgery. Similar doubts have been cast over surgery for hypospadias. Patient narratives point to the potential harm of multiple operations and repeated genital examinations.The rate of female assigned and surgically feminised children who reassign as male is of concern. Surgical techniques for childhood conditions can change long before adult outcomes are known, and experts in surgery have so far been unable to reach a consensus about the best operation. Parents may not realise that they are de facto opting for experimental surgery on their children. Furthermore, their emotional states during decision making may not be optimal. Research suggests that medicalised presentations of genital difference have undue influence on parental decisions and that parental regret can be high. Credible alternative