Indian Journal of Urology: “Female assigned genetic males with severe hypospadias: psychosocial changes and psychosexual treatment”

Three children aged thirteen, eleven and six were reassigned to a male gender role having been assigned and raised female from birth. The older two were able to participate in the decision making and, judging from this report, were already exhibiting perceived stereotypical male traits and behaviors prior to the decision being taken. The adjustment of the six year old is not known.

Gender assignments in cases of genital ambiguity should always be regarded as provisional and adjusted with patient consent.

Conclusion

Assignment of genetic males to female sex because of severe hypospadias and phallic inadequacy can result in unpredictable sexual identification. Androgens have long been thought to influence prenatal brain development as well as postpubertal activity, interests and libido. The ability of androgen to act on target tissues in utero could affect subsequent sexual identity. Children who are genetic males with severe hypospadias but wrongly assigned females at birth should be reassigned as males. Psychosocial changes in environment, school, home and relations must be made. Psychosexual counseling and orientation will help the children to cope with their new identity.

Indian Journal of Urology: Female-assigned Genetic males with severe hypospadias: psychosocial changes and psychosexual treatment

Introduction

Disorders such as severe hypospadias presenting as ambiguous genitalia have serious and potentially life-long consequences for affected individuals and, depending on the underlying cause, are likely to entail surgery in childhood and in later life, psychosocial and psychosexual support and possible fertility treatment including assisted conception.

Case 1

A 6-year-old girl child was brought to the Urology OPD with history of large clitoris. The child was the last of six children, with three elder brothers and two elder sisters. All the other siblings were normal. The child was shy and appeared timid. Examination revealed that the child had perineal hypospadias with bifid scrotum and small penis with severe chordee. Testes were palpable bilaterally, but of small volume. The right testes was retractile. Abdominal ultrasonography revealed no abnormality.

Genitourethrography revealed a normal proximal urethra. The case was discussed with the parents and elder brother. The child underwent psychiatric evaluation. Paediatricians, Psychiatrist, endocrinologist and social workers were involved in making a decision of sex reassignment. The parents strongly felt that the child needs to be brought up as a male. The child was put on hormonal treatment. The child’s name was changed; the child was admitted in a school at his maternal uncle’s place. The child underwent multiple sessions with the clinical and child psychologist. Over a period of 6 months the child started accepting his gender. Hypospadias surgery was done in two stages. The child has been on follow up since then. The child is still shy and does feel awkward in a boy’s dress. The child has male friends though not aggressive in playing with them.

Case 2

A 11-year-old girl presented with genital virilization. On examination, the child had severe perineal hypospadias with small penis. The child had bifid scrotum with the right testes not palpable. The child was male on investigation. The child and his parents were inclined towards reassignment of gender sex to male. The child underwent counseling and hypospadias repair. Right-sided laparoscopic orchiopexy was done in the same sitting.

Case 3

A 13-year-old child presented to urology OPD with history of fascial hair and genital virilization. The child preferred dressing as a male and liked to play with male children. On examination, the child had severe perineal hypospadias with a small penis and bilateral small testes. This child and her parents readily agreed to reassignment to male gender. The child underwent counseling and hypospadias repair.

Discussion

Once the diagnosis of a genetic male was made, the parents were informed and counseled. Decision to bring up the children as males was made by the parents after a detailed discussion with psychiatrists, urologists, paediatricians and family physicians.

The children with their parents were informed regarding the need for genital reconstruction, reorientation of the child to male sex, need for multiple sessions of surgery, failure of surgery and eventual outcome. Social changes were advised, such as, changing over to a boy’s school, hair cut and a male name. Relocating the child to newer environment, change of residence, change of school was advised to reduce peer pressure.

Conclusion

All the three children are on follow up of more than 15 months. They have been attending school as male children and have become well adjusted to their newer identity. The older two children have been experiencing erections and all three are having good urinary flow. The two older children have been playing with other boys and are comfortable in their new identity. The smallest of the three has overcome his shyness over a period of 12-15 months.

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