Minimal surgical intervention in the management of intersex conditions

The surgical correction of ambiguous genitalia has been a significant part of treatment for intersex conditions for the last 50 years, based on the belief that the child will be psychologically damaged by the uncorrected appearance. Despite widespread adoption of this policy, there is no evidence in the literature to support this approach. More commonly, the primary indication appears to be for the relief of parental anxiety. However, patients are increasingly expressing dissatisfaction with previous management, arguing that surgery should only be performed for strictly defined medical indications. Surgery may comprise treatment for the absent or shortened vagina, or for the correction of virilised external genitalia. The timing of such surgery is controversial, with many surgeons believing that a 'one-stage' procedure in infancy is appropriate. However, given that the vast majority of patients require further surgery at adolescence, others argue that deferral of vaginal surgery until after puberty is more appropriate. The role of clitoral surgery is contentious with many questioning the necessity of any operation in childhood for cosmesis which may impair subsequent sexual function. Despite claims that newer surgical techniques lead to a better result than previously, there remains little information in the literature regarding long-term functional outcomes following clitoral reduction procedures. Alternatives to vaginal and clitoral surgery are considered in this article. Vaginal operations should almost always take place at adolescence, given the poor outcomes of early surgery. When clitoral operations are performed, this should be for severely virilised individuals, with surgery best avoided for those with only mild or moderate virilisation.