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    Policymakers consider intersex surgical standards

     

    Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

    Proposals to regulate treatment of sex development differences threaten to further confuse patients and physicians. Too often, urologists fail to make their voices heard when policymakers consider instituting intersex surgical standards. A lone voice in Nevada hopes to add nuance to legislation governing a child's consent.

    As indicated by a dialogue taking place at UrologyTimes.com following the July 5, 2016, publication of an awareness-raising post entitled, The transgender community: Urology has a role and responsibility, physicians might well-benefit from continuing education on distinctions between differences of sex development (DSD) and gender dysphoria. Responding to the online publication, a concerned grandmother pointed out that associating congenital adrenal hyperplasia (CAH) with "bathroom bill" controversies overstates any connection between an inherited condition and one's psychological understanding of their gender identity. In fact, CAH patients and all other intersex people identify as transgendered or transsexual at the same rate as the non-DSD population, according to the Intersex Society of North America.

    Bills prohibiting surgery on minors with intersex traits (2017)

    Indiana

    House Bill 1461

    Nevada

    Senate Bill 408

    Texas

    Senate Bill 1342

    Organizations that promote national medical policy standards and lawmakers in several states (Texas, Indiana, Nevada) have recently considered proposals that would direct scrutiny upon surgical procedures undertaken in infancy to assign or confirm gender.

    The AMA House of Delegates took up a 2016 resolution proposed by the progressive Medical Student Section, which asked:

    That our AMA affirm that medically unnecessary surgeries in individuals born with differences of sex development are unethical and should be avoided until the patient can actively participate in decision-making.

    More from AACU - JAC 2017: IPAB repeal, liability reform see renewed focus

    At its June 2016 meeting, the House of Delegates referred the resolution to the Board of Trustees, which issued its own report later in the year. That report was temporarily shelved after receiving divergent testimony regarding unintended consequences, "particularly around interventions that may be clinically necessary but not life-threatening or emergent." Delegates noted that when this report is reconsidered, "the recommendations should be developed in collaboration with experts in pediatric endocrinology, urology, psychiatry, and law."

    Unfortunately, that kind of collaboration is being rejected by proponents of a bill progressing through the Nevada Legislature. Senate Bill 408 prohibits any surgery to assign anatomic sex of a child, including relocation of the urethral meatus, unless he/she is capable of assenting to the procedure. An exception may be made if the provider determines that delaying the procedure is likely to endanger the child's life, but the bill includes no other nuance. The broad measure essentially legislates a definitive DSD standard of care unless/until lawmakers come together to amend the law.

    Next: "This is a complicated area of medicine that is undergoing rapid re-evaluation."

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