Gynaecological and Psychosexual Outcomes of Feminising Genital Surgery

Childhood feminising surgery remains standard clinical practice for those bom with ambiguous genitalia, such as women with Congenital Adrenal Hyperplasia (CAH). The aims of such an intervention are to promote “normal” female appearance, allow comfortable penetrative intercourse with unimpaired sensation, avoid increased psychological sequelae and prevent urinary difficulties due to anatomical variations. However, these aims remain largely unevaluated. Little is known about the range of normal female genital appearance with few objective m easurem ents in the literature. Scanty long­ term data is available regarding sexual function and sensation following childhood feminising surgery. To date there is no evidence to suggest that childhood surgery reduces psychological distress compared with those who did not have operations. Finally, no studies are available assessing urinary outcom es following surgery. These areas are assessed in turn, starting with a study to ascertain normal female appearance of the genital area, and to illustrate the variations of normality. Genital sensation is next considered, with a study of 28 women with CAH who underwent objective sensation testing to the clitoris, where surgery had taken place, and to the upper vagina, where no operations had been performed. This data was compared with 9 normal subjects who had no history of sexual function difficulties or previous operations to the genital area. Clitoral sensation was significantly impaired in those who had undergone surgery, but not vaginal sensation. Sexual function and subjective views regarding surgery were assessed , with 32 women with CAH recruited to complete a detailed questionnaire assessing various aspects of anatomical and psychosexual function. This was then compared with data from 10 normal controls, showing women with a history of surgery had increased sexual function difficulties. Finally, a further study assessed the degree of lower urinary tract symptoms in those who had undergone surgery, and compared this with a normal control group. This showed increased urinary tract symptomatology in the group who had undergone childhood surgery. The results of these studies are discussed and considered in the context of current knowledge of intersex research. Recommendations for clinical practice and future research are given. Gynaecological and Psychosexual Outcomes of Feminising Genital Surgery 1 Declaration The research leading to this thesis was carried out in the Middlesex Centre at the Elizabeth Garrett Anderson Hospital and the Academic Department of Obstetrics and Gynaecology, Univeristy College London. All work contained in this thesis is my own. None of the data forms part of any other thesis. All studies were approved by the Joint University and Hospital Ethics Committee, with written consent obtained from all participants prior to their involvement.