Who gets to decide a child’s gender?

A 5-yr-old from Nashik recently underwent a sex re-assignment surgery after parents discovered he had both male and female sex organs. His parents took the decision to have his ovaries removed

Recently a child was operated upon at Parel's King Edward Memorial Hospital for Mixed Gonadal Dysgenesis, a condition in which the child's sex organs aren't clearly male or female. While doctors at the civic body-run hospital performed a sex reassignment surgery on the five-year-old, removing the female organs and thus, ensuring that the child would function as a boy henceforth, there is growing concern that in the absence of a law governing such cases the rights of the child could be denied.

Doctors in India say that in such instances, considering that children are too young to give their consent for such operations, the parents' decision regarding which gender be assigned to the child is taken into account. Of course, the child is subjected to a series of physiological and psychological tests before the surgery is performed. In countries such as the US and UK as per law patients have to wait till the age of 18 years when their own preferences are acted upon.

Battery of tests before surgery
Speaking on practices in India, Dr Sanjay Oak who is a senior paediatric surgeon and the dean of KEM Hospital said, in cases where the child is brought in with underdeveloped genitalia the patient is made to undergo tests - genetic chromosome, hormonal, neurological tests, sonography (to determine which organs are missing or if they are placed wrongly in the body) - to determine if the child's body is male or female or has the hormones of any one gender more than the other

Once the gender is determined the patient is made to undergo psychological evaluation to understand if the child has been raised as a male or a female and if he/she would be comfortable with a gender reassignment.

For instance, the Nashik child had been brought up as a boy. However, his physiology showed that both the male and female sex organs were present though under developed.

He had female organs such as the uterus, fallopian tube and ovaries. He also had an underdeveloped penis. The child's family which discovered the birth defect only five years after he was born had raised him as a boy.

Dr Oak, who has performed 10 such surgeries on children aged between 5 to 12, insisted, "We don't operate on patients blindly." The Nashik child was put through a psychological evaluation and the doctors found that he was behaving as a boy. Even the parents, during their counselling sessions, insisted that their child's female organs be removed and his testicles and penis be reconstructed. Additionally, Dr Satish Kapdnis, KEM's paediatrician, said that tests showed that despite having female organs the child also did have the right side testes and undeveloped penis. His hormone and chromosome tests also showed that his body functioned as a male rather than a female.

Of course, the child's consent was not taken. Would it not be better to leave the patient the option of deciding his/her own gender once an adult?

Arguing that there are social pressures that need to be taken into account, Dr Nitin Dhende, senior pediatric surgeon at JJ Hospital said, that the country's culture would not be conducive for a child to be assigned a gender that late in life. In other countries the child is raised, again as a girl or a boy depending on the parents' preferences, he added. "However, the child is made aware of the condition and told that he/she can make the choice when of age."

But the argument here is, according to Dr Oak, the quality of life the child will lead if he/she has male organs while also developing breasts. "A person's identity is very important. Where will this child study? What he will wear? There are many aspects that need to be considered and if that's not done it could push the child to the brink of suicide."

Preference for the male child?
There have been cases, doctors say, where the parents have insisted on having the female organs removed.

Dr Dhende added that as per medical ethics guidelines, the surgery can be conducted only in essential cases. Opinions of endocrinologists, psychiatrics, neurologist, plastic surgeons paediatricians need to be taken before going for surgery.

Dr Oak, who said that across Mumbai over 20 such cases were reported in the last one year alone, talked about two instances where a 7-year-old and a 8-year-old boy were brought to the hospital.

Tests revealed that the children had a greater concentration of female hormones and chromosomes in their body. "The parents were not ready to accept this fact. But repeated sessions with our physiologist and psychologist helped convince them. The surgeries were successful and both girls are leading normal lives now." The decision, the doctor said, must be taken as early as possible, preferably before the child goes to school.

What remains to be answered is if it is fair that a person is not allowed to participate in the most important decision of his or her, as the case may be, life?

Mixed Gonadal Dysgenesis
- MGD is one of the most common disorders of sexual differentiation and the second most common cause of ambiguous genitalia in newborns
- Gonads are the body' sex organs. Boys develop gonads called testicles and females develop gonads called ovaries
- A child with MGD has an undescended testicle on one side and a dysgenetic (improperly developed) gonad on the opposite side
- Since MGD causes a child's genitalia to be ambiguous, babies aren't born as "girls" or "boys"
- They are assigned a sex after they're diagnosed with MGD
- Typically, the decision on whether to raise a child with MGD as male or female is based on anatomic findings » MGD can sometimes be inherited, but is most often idiopathic, meaning it has no identifiable cause
- The complexity of treatment varies depending on your child's exact anatomy
- Sex assignment is extremely crucial for treatment purposes as well as the emotional well being of the child.

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