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Handbook of Clinical Gender Medicine


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      Anatomical Aspects of the Insufficiently Developed Genital Tubercle

      Sexual Identities

      Understanding of and decision making for a child in the neonatal period with severely abnormal genitalia is an extraordinary challenge. It is quite paradoxical to opt for a gender without consulting the patient himself or herself. This process has been highly criticized by some patients and patient advocacy associations and remains quite controversial. To understand the complexity of these situations, one could distinguish three different identities. Individual sex identity, which is what the individual thinks he or she is, is quite a subtle spectrum and will be shaped by growth and external and internal influences. Behavioral identity, which is the individual’s erotic inclination, will also form with time. Both of these identities are invisible in the neonatal period. The last identity, i.e. social identity, (or gender) is how society looks at the individual and recognizes the individual as male or female. Social/gender identity is far more rigid, and less subtle, than the others. It is the way the social mirror reflects the individual’s image, i.e. the way to make the individual visible. It is the only tangible identity at birth.

      Decision Tools

      Hormonal Treatments

      Masculinization Surgery

      DSD surgery should be done by DSD surgeons, i.e. surgeons familiar with genital reconstruction in children. Hypospadias reconstruction is commonly performed between 6 months and 2 years of age and includes three main steps. The first step is full dissection of the GT to expose the level of division of the corpus spongiosum which is the proximal landmark of the GT anomaly. It is then possible to evaluate the quality of the tissues available and choose the most appropriate technique for urethroplasty. In the second step, the choice of urethroplasty is dependent upon the length of the urethra to reconstruct, the quality of the urethral plate, the size of the glans, and the availability of dorsal tissues. The third step consists of refashioning the ventral aspect of the GT by redistributing the tissues around the penis, with or without conservation of the foreskin. There is no universal technique for hypospadias repair and no gold standard technique. The outcome is dependent upon many factors, the most important of which is the experience of the surgical team and the quality of postoperative care.