1

Precious Chukwukezie
Bard College Berlin
Spring Term 2023
Medical Ethics
Sinem Kilic
Ambiguous Genitalia in Medical Ethics

ABSTRACT
sexuality or sex (identification)? different things i
think - double check
Although sexuality can be deemed intimate and personal, it is often subject to power
relations in both the private and public domains and is highly politicized and socialized.
It is therefore, a biological conception(influenced by patriarchy), that there can only exist
one sex in a person, but ambigusexuality has defeated this study. However, it is
medically termed “abnormal” to have a dual sexuality. In Nigeria specifically,
ambigusexuality is considered an illness rather than a condition; therefore, it is only
“normal” that one is operated to “fix” their sexuality. This paper will question the ethics
behind operating on intersex children (infringing their autonomy), as well as question the
no brackets - instead “through a conversation on autonomy”
moral principle of nonmaleficence and beneficence on grounds that- if the complex
genitalia don’t discomfort the child or cause pain, would operating on the child then be a
good act, or could this decision made by the doctor and the child’s parents possibly
cause more harm than good in the child’s future? What if the child wanted to identify as
the already removed sex? Is the doctor’s discretion one that concerns conforming a
person to a particular sex or upholding binary sex for social, cultural or religious
reasons?

Introduction
Intersexuality is a term used to describe individuals who are born with ambiguous
genitalia or genitalia that do not fit the typical male or female categories. Intersexuality is
a relatively common condition, with estimates suggesting that up to 1 in 2,000 babies
are born with intersex traits(Hermer, 2000). While the external genitalia may appear
male, for example, the person also possesses ovaries rather than testes, and a
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functional uterus. Or a person may have a bifurcated scrotal sac/vulva and a urethral
opening at the base of what appears to be a small, curved phallus, but, upon surgical
exploration, has undescended testes and no female reproductive organs. While
identification of a child as intersex can often be made by physical examination alone, in
some cases normal-appearing external genitalia can hide an internal ambiguity or an
anomalous chromosomal sex(Hermer 2002).
small thing - no gap between paragraphs and indented first line (by
clicking ‘tab’ on ur keyboard with cursor at beginning of the line)
In the 19th century, medical science became increasingly interested in intersex
conditions. Doctors began to study and classify these conditions, often using invasive
no procedures and treatments. One of the key figures in this field was French physician instead of
quote Ambroise Tardieu, who published a book in 1869 called "Étude médico-légale sur les “- An”,
marks - maybe
instead hermaphrodites" (Medico-legal Study of Hermaphrodites)- An excerpt from Michel “which is
use Foucault’s Memoir of Barbin in his book, Queer Monsters. In this book, Tardieu outlined also
italics add year in brackets and italicise features
for a classification system for hermaphroditism, based on the presence of male and female as”
names so-called hermaphroditism (i think this is an outdated term)
sexual organs and secondary sexual characteristics. He also advocated for surgical
of texts
interventions to "correct" these conditions. Other doctors of the time also experimented
with surgical interventions, such as castration or the removal of ovaries or testes, in an
attempt to "normalize" the bodies of intersex individuals. These surgeries were often
is this quoted from a text? if so cite page and text
performed without informed consent, and many individuals suffered lifelong physical
and psychological trauma as a result(Hermer, 2000).

One particularly infamous case from the 19th century is that of Herculine Barbin, who
was born intersex in France in 1838. Barbin was assigned female at birth, but later in
life it was discovered that they had both male and female genitalia. Barbin was
subjected to medical examinations and interventions throughout their life, including
genital surgeries and hormone treatments. They later committed suicide at the age of
30, possibly due to the trauma of their experiences.
There are a myriad of diagnoses for intersex conditions
Intersex conditions are myriad in number and type; virtually all develop in utero. Around
the age of six weeks, an embryo develops undifferentiated gonadal tissue, which may
become male or female, depending on the presence or absence of certain genetic and
 where are these
facts on intersex 3
conditions from? what are these factors? a bit confusing
are they cited?
hormonal factors. In the absence of these factors, an embryo will develop into a female,
but in their presence, it will develop into a male. Intersex conditions can develop when
an abnormality develops with respect to the fetus' sex chromosomes and/or hormones.
Intersex conditions may be classified in a number of different ways. Most frequently, the
medical literature - as a residual of the former primacy of gonads in defining sex -
groups intersex individuals into "true hermaphrodites" and "pseudohermaphrodites".
True hermaphrodites are characterized as having both ovarian and testicular tissue.
Pseudohermaphrodites, on the other hand, have gonadal tissue of only one type
(Hermer 2002). and identify with a different sex… or?

Case for reference

In 1999 two men in their early twenties, one from the east coast and one from the
…of the USA
midwest, independently contacted Professor Milton Diamond and revealed their
extraordinary stories. When they were infants, their testicles were surgically removed
and their genitals reconstructed. They were then raised as girls. As puberty
approached, they were given female hormones to make their breasts grow and to force
other female characteristics to emerge. They described their childhood bewilderment to
Professor Diamond. They had never been comfortable as girls; they recalled always
harboring inner thoughts that they were male. However, fear had prevented them from
giving a voice to their doubts. One young man recalled asking his mother,"Does God
cite
make mistakes?" They described the shock they felt when in their teen years they
pieced together information about their medical conditions and learned about secret
surgical procedures performed on them when they were too young to remember or
consent(Beh & Diamond, 2000).

Questioning moral principles in medical ethics

Medical professionals base their actions on grounds of moral principles governing
medical practices. In a real sense, doctors cannot act on their personal discretion.
When faced with a dilemma, they must act according to the moral principles. There are
maybe list briefly to provide overview
five moral principles in medical ethics, but this paper would question three of the moral
restate which are questionable and thus which will be discussed
principles in the acts of physicians. By comparing each of the principles with the above
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mentioned cases and evaluating the after effects of the acts by the doctors and
everyone involved in these cases. The first is the principle of nonmaleficence; this
principle asks not to intentionally or unintentionally inflict harm on others. A more
precise formulation of the principle is: We should not cause unnecessary injury or harm
to those in our care(Lewis Vaughn, 2019). In the case of the two men who contacted
professor Milton, do we say the physician was following this principle when they
surgically removed John’s testicles and injected female hormones in them so they could
become women? Have the pain they felt growing up not defeated whatever reason their
reassigning their sex
doctors have for reassigning them at birth?
The second principle is the principle of beneficence. Similar to nonmaleficence, this
principle asks to do good to others as well as advance their welfare. In the same case of
is it possible
the two men who contacted professor Milton, do we say the doctor was doing good to
to know this?
i thought the them by going ahead to conform them to female sexes without knowing what sex
point of sex is
exactly they belong to? Or the lack of investigative facilities before gender
that it is i think this is
assigned. reconstruction. As seen in the case presented in the University of Benin Teaching the first time
maybe “what
Hospital and Leadeks Medical Center, Nigeria, where a total of 40 female children were that gender is
sex they are mentioned. i
more likely to seen with congenital aberrations of external genitalia. Those with clitorimegaly due to think it’s
identify with” congenital adrenal hyperplasia were mistakenly raised as males, despite obvious necessary to
define sex and
abnormality of external genitalia of the 20 female pseudohermaphrodites, wrong gender gender in the
was assigned (Osifo & Amusan 2009). Or even the case of the 6 year old female who introduction,
and explain
had to go through the same pain of genital operation over again because of mistaken what
surely this assignment(Osifo & Amusan 2009). The above mentioned cases, were the doctors distinguishes
isnt the issue them from one
- the issue is doing good to them by assigning wrong sexes to these infants? -another
choosing for The third principle is the principle of autonomy. This principle is one that gives a patient
them right?
power to decide on what they want for themselves. It states; autonomous persons
should be allowed to exercise their capacity for self-determinationI(Vaughn 2019).
is
However, if a person is not autonomous, i.e are not rationally competent enough to
make decisions for themselves, paternalism could be considered. Paternalism is
defined as the overriding of a person’s own actions or decision-making for his or her
own good(Vaughn 2019). Paternalism is best advised when there is a life threatening
situation or a discomfort in a patient’s life. Taking the case of the 40 children from the
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University teaching hospital whose autonomy was ridden “for their own good” because
they weren’t rationally competent enough to make decisions for themselves. If the
How is a
ambiguity of their genitalia wasn’t life threatening, or causing discomfort to the children, definitive
assignment
is it justifiable to override their autonomy even if they weren’t competent enough for
more beneficial
decision-making? How is a mistaken assignment then for the good of these children? than the
potentially
If the act of reassignment of these children's sexes defiles three of five moral principles potential risks
of mistaken sex
in medical ethics, why then is it still being practiced? Why is it still a legal act in medical assignment?
practices? Is there perhaps social and/or cultural beliefs influencing the
decision-making?

Societal norms and medical practices

Nigeria as a state, most of the laws and social practices are influenced by cultural
beliefs. One of which is that a person can only be a man or a woman. Anything outside
of that is considered abnormal. Many Nigerians are unaware of what intersex is, and
some view it as witchcraft that requires deliverance or execution by stoning. Others
consider them to be cursed. Because of this, every intersex person in Nigeria deals with
the major issue of discrimination from family and society. Many of the intersex people in
Nigeria go into hiding because they are afraid of how society will view them. One of the
very famous cases of intersexuality was that of Mystique Evolving- A Nigerian person
whose external organs showed they were male from when they were born. But as they
grew older, they possessed characteristics of a woman and secreted a higher
percentage of estrogen than testosterone, which made them look more feminine but
have masculine organs. During her high school, she was accused of being gay, but she
knew that wasn’t her sexual orientation. Mystique claimed that, with the exception of
one of her brothers, her family had rejected her for more than ten years. "The last time I
saw them, they nearly murdered me, I was beaten, my hair was shaved, and I was
kicked to the ground." She said during her interview with BBC news pidgin.
These are one of the problems doctors and parents go through when faced with the
condition of ambiguous genitalia in infants. With fear of the child being discriminated
against and ridiculed in society, also the fear of accepting what is outside the “societal
norm”, the child’s parents as well as the doctor is forced to reassign the child to conform
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to a “normal” sex. But does this change the fact that the child’s autonomy was infringed,
thereby breaking the moral principle?

Legal standings
Government agencies in the United States, Germany, Switzerland, Australia, Chile,
Argentina, and Malta have studied the issue. In 2016, the United States Bureau of
Public Affairs issued a statement on behalf of the State Department that acknowledged
that medical surgeries conducted on intersex children without their free and informed
consent “jeopardize their physical integrity and ability to live free.” 1 In 2012, the
German Ethics Council called for a deferral of these surgeries until the children are old
enough to consent and concluded that “irreversible medical sex assignment measures
in persons of ambiguous gender infringe the right to physical integrity, to preservation of
sexual and gender identity, to an open future and often also to procreative
freedom”(Greenberg, 2017).
There may be resistance to passing laws that protect intersex individuals due to
concerns about violating cultural or religious beliefs. Some societies may view intersex
variations as a deviation from traditional gender norms or as a sign of immorality, which
can lead to stigmatization and discrimination. Laws and policies that protect intersex
individuals can help to promote greater understanding and acceptance of intersex
variations, reduce stigma and discrimination, and promote greater respect for human
rights.

Conclusion
The commonly held idea that there are only two distinct biological sexes is a
simplification of a much more complex reality. While it is true that the majority of people
are born with either male or female reproductive anatomy, there are many individuals
who are born with atypical sexual characteristics that do not fit neatly into binary
categories. It is important to revisit the moral principles in medical ethics in cases of
intersex children in order to prevent potential psychological harm.
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Intersex medical interventions have historically been performed on infants and young
children without their informed consent, and many intersex individuals have reported
significant psychological harm as a result.

The principle of respect for autonomy is a cornerstone of medical ethics, and it applies
equally to intersex individuals. It is important to ensure that intersex children are not
subjected to non-consensual medical interventions that could cause physical or
psychological harm.
One approach to addressing this issue is to promote a "watch and wait" approach to
intersex medical interventions. This means delaying interventions until the child is old
enough to make an informed decision about their own medical care. During this time,
the child and their family can receive support and information about intersex variations,
allowing them to make an informed decision about what course of action to take.

Bibliography:

Chime, Onyinye. “Intersex: Wahala Wey Intersex Pipo Dey Face for Nigeria.” BBC
News Pidgin, 2019.

Greenberg, Julie A. “International Legal Developments Protecting the Autonomy

Rights of Sexual Minorities: Who Should Determine the Appropriate Treatment for an
Intersex Infant?” International Library of Ethics, Law and the New Medicine, 2017, pp.
87–101., https://doi.org/10.1007/1-4220-4314-7_5.

Hazel G. Beh & Milton Diamond, An Emerging Ethical and Medical Dilemma: Should
Physicians Perform Sex Assignment Surgery on Infants with Ambiguous Genitalia?, 7
MICH. J. GENDER & L. 1 (2000). Available at:
https://repository.law.umich.edu/mjgl/vol7/iss1/1

Hermer, L. (2002). Paradigms revised: Intersex children, bioethics & the law. Annals
of Health Law, 11, 195-236.
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MALATINO, HILARY. “Queer Monsters: Michel Foucault and Herculine Barbin.” Queer
Embodiment: Monstrosity, Medical Violence, and Intersex Experience, University of
Nebraska Press, 2019, pp. 39–70. JSTOR, https://doi.org/10.2307/j.ctvckq9pv.7.
Accessed 19 Mar. 2023.
Osifo, Osarumwense D., and Taiwo I. Amusan. “Female Children with Ambiguous
Genitalia in Awareness-Poor Subregion.” African Journal of Reproductive Health / La
Revue Africaine de La Santé Reproductive, vol. 13, no. 4, 2009, pp. 129–36. JSTOR,
http://www.jstor.org/stable/27802629. Accessed 19 Mar. 2023.
Vaughn, Lewis, et al. “Chapter 1 and Chapter 3.” Bioethics Principles, Issues, and
Cases, Oxford University Press, New York, NY, London, 2023, pp. 10–105.