Genital surgery among females with congenital adrenal hyperplasia: changes over the past five decades.

The treatment of intersex patients, including any patient born with genital ambiguity, is being reassessed. The re-evaluation is primarily focused upon the indications for and age of genital surgery, the impact of prenatal androgen levels upon gender development, and the potential for maximum sexual responsiveness as an adult. As a background to document changes in genital surgery for females with 21-hydroxylase congenital adrenal hyperplasia, this report is a review of surgical treatment of this most common form of genital ambiguity. Results document changes in the 1960s from clitorectomy to clitoroplasty using more refined techniques, but more interestingly a choice by parents against any surgery during childhood. This shift preceded the current impetus from intersex support groups. It appears to result from an appreciation by parents of variation in female genital configurations plus a realization that the clitoris will regress with the withdrawal of excessive androgens with relative size diminishing as growth proceeds. The primary impetus for this shift apparently has not been to preserve the vascular and neural supply to enhance sexual responsiveness, since parents in the past assumed that such could be preserved with appropriate surgical techniques.