By Michael Kreuzer, MD
March 15th, 2019
Lane Palmer has written several articles on the subject of restricting and delaying non-therapeutic elective surgeries on infants and children and each and every time he has tweaked facts to favor his own arguments or confused biological sex with gender identity. I am a physician too, and I can absolutely with evidence base refute all his statements. My rebuttal just as his latest article are opinions, but I can back my statements up with facts.
Lets look at the article, he says: ‘”Intersex” is an umbrella term used to describe a wide variety of conditions in which an individual’s genitalia does not match standard definitions of male or female.’ – To be very clear, we are talking about male and female by biological sex, not gender! This is crucial in understanding intersex or the medical terminology which is often used synonymous Difference (less preferred Disorder) of Sex Development, DSD. Intersex exclusively describes various biological sex traits which are not typical for what is generally considered male or female biological sex traits. In other words intersex (or as previously known as hermaphroditism) is the manifestation of…drum-roll.. the non- binary in biological sex in human beings, it is a variation that occurs in nature and is NOT abnormal, pathologic etc.
He continues to write: ‘This may include variations such as genital ambiguity, hormonal issues, deviations in sexual phenotype, or aberrations in chromosomal genotype. For some of these young patients, their physiology is medically healthy, despite differences from the norm. For others, there may be serious medical complications necessitating surgery.’ – This is very unspecific coming from a specialist like him but there is a small minority of newborns with intersex or DSD who have severe malformations of the urinary tract, which might be the inability to urinate sufficiently or their bladder might be exposed which means on the outside of the body. Some infants are also found to have tumors of the kidney(s). Other than those cases there is need for emergent or therapeutic elective need for surgery on the urinary tract or the genitals or gonads. Also terms like ambiguity, deviations and aberration are pathologizing, the reality is ambiguity, in this case, means that they are not male or female typical genitalia, deviations, in this case, means there is a difference in how a person appears on the outside (phenotype looking like a girl) and the inside (testicular gonads, XY chromosomes), again this is not a deviation this is another variation of the norm, also what he calls chromosomal aberrations are nothing but variations in i.e number of sex chromosomes XXY, XX/XY mosaic, X0 etc., this happens in nature and is not an aberration. It is important to keep this medicalizing/pathologizing language here in mind for later in the article.
He continues: ‘The privilege of having all viable options and potential solutions on the table is something that families cannot afford to lose while making the most consequential health decisions of their lives.’ – Surgeries on infant genitalia or removing their gonads thus technically sterilizing them are not what I would consider a viable option, in particular, if they have only cosmetic indications (like i.e. breast augmentation). Nothing else as far as management is being changed, the only change is the postponement of non-therapeutic elective procedures, all other ‘viable’ options remain on the table.
He goes on: ‘The first issue that needs to be addressed regarding this legislation is its gross simplification of intersexuality. What the bill labels as intersex actually encompasses approximately 30 different conditions, each distinctly unique, and each requiring its own specific treatment and set of considerations. The overwhelming majority of patients who label themselves as intersex do not in any way question their gender. This is one of the most critical facts this legislation fails to recognize. To speak of this broad spectrum of people as if they are some a monolithic group stuck between genders, all with identical interests, is not only a great disservice to the diversity and pluralism of the broadly intersex community but is unethical in principle.’ – It is indeed DSD that encompasses over 30 intersex traits, called conditions by him, a term that medicalizes intersex traits. The only actual condition here is the human condition, these people are all human. Intersex advocates very much understand that this is an issue of biological sex characteristics, intersex is NOT a gender issue, and that is the problem here. There is a lack of understanding in the general population about intersex or DSD, which is the non-recognition of the fact that biologically speaking humans are not binary, are not male and female, there is more, this has always been the fact and always will be. Hermaphrodites are mentioned in the Bible. My other question is if this is such a varied population why does the majority get this monolithic approach by the medical community of ‘normalization’ towards either male or female biological sex in combination with very identical surgical procedures across the entire spectrum of intersex/DSD? Sounds like quite a monolithic approach by the medical providers. He is right, intersex people don’t question their gender once they are able to express it, however, what he is not mentioning is, society does. Why would we be surprised that a person who was born with i.e. XY chromosomes, testicular gonads and maybe difference in their genital appearance, after being assigned female at birth and basically having their small but existing penis removed so they might ‘look’ more like a girl, eventually say: I am not female! Does that make them gender dysphoric or a trans person? No, I would argue that surgery artificially created this without ever considering how the individual would identify. We cannot expect a person of non-binary biological sex to conform to a binary model, we should, however, respect their identity once they are able to convey it. They should not be denied to identify as ‘real men’ or ‘real women’ based on their anatomical, physiological or chromosomal differences. Nobody is stuck between genders, chromosomes, anatomy, gonads all of that does not define a person’s gender identity. Lane Palmer needs to brush up on his knowledge about the difference between biological sex and gender. It is unethical, however, to deny diversity of genitals or sex traits, as an argument that gender identity is expressed by those, and that is exactly what he is doing. By claiming that you can only live in a typical male or female body he takes away any variation of sex traits.
He then writes about CAH which by all definitions is an endocrine/metabolic issue and not a surgical one at least not in infants. He says: ‘Many females with CAH are born with externally fused vaginal canals, requiring surgical reconstruction in order to allow for proper menstruation. Failure to do so could result in severe illness as built up blood lacks an avenue for voiding, as well as precluding the possibility of reproduction. Most girls with CAH undergo feminizing genitoplasty procedures to ensure healthy functionality.’ – He just made a great point in favor of the bill. Do infants menstruate? Do children have intercourse? Should minors give birth? Generally, the answer here is “no”. The procedures can indeed wait, also in CAH with a very male exterior appearance the vagina is often connected to the urethra and yes potentially menstrual blood can drain. The problem here is the assumption that all people with CAH and XX-chromosomes will identify as female, what if one of those children identifies as male? The other problem is the assumption that all XX- CAH people want children or penetrative intercourse, what if they don’t?
He then goes on: ‘There have been cases where some have waited, but such patients have overwhelmingly indicated that they wish they had undergone the procedure when they were infants. In fact, nearly 90 percent of CAH patients believe that the procedure should be done within the first year of life.’ – I wish he would give a reference to actual data because I have read many articles and his statement is not confirmed. The really interesting numbers are the numbers of people who refuse to answer any follow-up questions about their childhood surgeries, over half of the population. One would think if these procedures where so great and lifesaving a lot of people would want to come out to support them. Try to take open heart surgery away and you will understand what I mean. Even if I bought into his numbers, his argument is still weak, he says 90%, what about the other 10%? What about their suffering? What about the reality that they might have to now undergo more procedures to reverse what was done in childhood, while being scrutinized and discriminated for it, not unlike transgender people. Is it acceptable to basically ruin the lives of 10% of the population to give the other 90% something they could have had anyway, just would have had to wait a little longer? In my opinion, the answer is, no. It directly violates the principle of Do No Harm. We cannot say that just because the majority is happy with the result of a surgery that is a non-therapeutic elective surgery done in infancy or childhood, and can be performed later in life, should be performed earlier, when we risk that a significant number of people will be negatively affected, even if they are a minority. Besides if a surgery is needed to i.e. ensure menstrual flow, of course, it can be performed, to claim this bill disallows that is basically a lie.
He continues: ‘A vocal minority of activists has convinced well-meaning individuals and politically sensitive legislators to support this bill based on its political merits while ignoring the voices of those they purport to protect.’ – That is actually not true. The fact is that most intersex/DSD individuals who are open about their status, are opposed to surgeries. This community is closeted to begin with. To put it in perspective the population of intersex/DSD people in the US is roughly equal to the transgender population about 2%. Who do you hear more about? Hard to believe there are so many intersex/DSD because he sure makes it sound that there are much less. Even people who are not out and not activists share their displeasure with surgeries i.e. in secret groups on FB. Attempts have been made to find people who would stand up to testify for their surgeries, they can rarely be found, very small numbers are out there who would be willing to give such testimony. Lane Palmer who takes his input from CARES might not know that. CARES, a support organization of individuals with CAH and their parents, supports surgeries and here and there manages to have a few of their members speak out in favor of surgeries, most of the time anonymously behind a plant.
Then he actually goes quite far and leaves the basis of fact behind: ‘The bill constitutes an aggressive abrogation of parental rights. It is egregious for such an important decision to be appropriated by government officials and politicians away from parents. Barring medically necessary emergencies, such decisions rightly fall under parental purview. Monolithic legal injunctions are wholly inappropriate, given that the complexity of the issue necessitates each case being considered individually, with cultural and familial considerations being given their due weight.’ – In this bill there is no restriction on any emergent or lifesaving procedures and he seems to claim that. He talks about parental rights, but he never even once mentions that physicians are more than happy to take parental rights away if they consider the parents unfit. The Jehovah Witness child who needs a blood transfusion, parents rights are taken away and blood is give. The child with cancer and parents refusing chemo, the parents are stripped off their rights and the child receives chemo. The teenager under 18 who wants birth-control or an abortion, in many stated physicians can facilitate that without ever involving the parents. Transgender children whose parents oppose their transition and want hormones, in many cases parental rights have been overturned. Parental rights are not the holy cow to physicians as he makes them out to be, his goal appears to try to incite parents. For him to use parental rights when he is also the one convincing parents that surgeries are needed, and at the same time is to vilify parents who refuse surgeries in spite of his recommendations, what does that make him?
He then writes: ‘Perhaps most alarming has been the impetus behind the legislation. It has not been informed by medical best-practices, current scientific literature, expert opinion, or a wide swath of patient opinion. It has been primarily driven by an extremely vocal, highly politically charged movement. For many patients, it has been frustrating and even heartbreaking for them to see their conditions co-opted by a political movement that does not represent their best interests.’ – I am extremely well connected with the intersex/DSD community, I am a physician, I am an intersex person, I have not encountered a single heartbroken individual who thinks that people like Lane Palmer have our best interest in mind. I am talking about hundreds and hundreds of individuals. Most intersex people do not think that Lane Palmer or any physician has their best interest in mind. Again, it is one organization, CARES, that promotes this point of view, and they do not represent the majority of intersex/DSD individuals, but they sure are vocal. I want to go even further, I have spoken to medical students, most likely 1000s of them, never have I had any open opposition nor negative feedback, although I encourage debate, about postponing surgeries. I am currently conducting research on follow up studies on all surgical procedures performed on intersex/DSD infants and children and my focus is on follow up with an emphasis of patient satisfaction and outcome other than just cosmetics (this is the outcome most surgical studies focus on). I have read and will include a number of studies which have indeed asked patients about sexual function, and it is evident from my readings that these surgeries do not help, as a matter of fact, many are left without the ability to ever achieve an orgasm. Of course, these studies cannot be conducted on children, children should not have an active sex life. They have to be conducted on adults which means they fall outside of the typical follow-up intervals for surgeries.
Then he writes: ‘Pediatric urologists, the doctors whose responsibility is to care for these children, are not pro-surgery any more than they are anti-surgery. What they do advocate is for parental and patient education, usage of evidence-based literature, family-centered care, a multidisciplinary approach, and an individualized focus informed by the child’s input and unique situation.’ – I have a problem with his point since in my experience a surgeon makes money from surgery and therefore will most of the time take a pro-surgery position if there is any doubt about the necessity of surgery. Even if I ignore the monetary incentive and assume he is an altruistic saint, he says the surgeons are the advocates. Are they? How is it possible that children and their parents who are referred to specialists are rarely given the opportunity to connect to parent support groups unless it is CARES which is the one group in favor of surgeries? What could have happened is we could have had a flyer in the OB/Gyn office while the parents were still expecting called: “What if it’s not a girl or a boy?” followed by a discussion at the next visit about the content of the flyer and the possibility of the birth of am intersex child. Expecting parents get information about much rarer conditions all the time. What about including intersex as a non-binary of biological sex in a biology or sex education classes in school, before people even start procreating? Now that would be advocating, I have never heard him make any such statements. Knowledge about intersex/DSD in the general population, rather than telling panicked parents who have never heard of such a thing that their baby needs genital surgeries, wouldn’t that be real advocacy?
His final paragraph is a testimony to his own self-righteousness if I may say so. ‘This legislation is anti-choice, anti-parental rights, anti-science, and anti-patient. There is absolutely nothing righteous or just about what this legislation seeks to accomplish. No doubt, many support this legislation out of a misguided belief that it is in the best interests of intersex patients. As a practicing pediatric urologist with decades of experience guiding patients and their families through the most challenging times of their lives, this legislation is unequivocally not in the best interests of anyone except the political actors pushing it. If we allow our conceit to get the best of us, we will have to reckon with the real harm this bill will ultimately inflict on patients and children.’ – I am saddened by the fact that this man and I share the same profession. I know at the core these providers do not want to inflict damage, they really believe they are helping, and they are doing the best they can. I believe that the parents who follow his recommendations love their child and believe they are doing the best. What I do not understand is that after all the very open push-back from the community, after over 20 years of trying to find a consensus between medical providers and advocates, he thinks he should take the high road. In my analysis there is probably a lot of internalized guilt because he must have gotten a ton of negative feedback, all providers get some, no matter how hard they may try. He might also face the real fear of lawsuits which could happen, once any procedure has been identified as harmful. For him to take a position as he does behind his overly confident and maybe a bit arrogant mannerisms a fear seems to be lurking and it is not for the intersex population, it is for him and his kind.
To give support against these unnecessary cosmetic sex assigning genital intersex corrective surgeries please see InterACT’s message:
California’s SB 201 would ensure the delay of medically unnecessary intersex surgeries, such as clitoral reductions, to give individuals their own choices about their own bodies. You can help! Share this video to learn about the bill, sponsored by interACT, Scott Wiener, Equality California, and the ACLU of Northern California.