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Clitoral Sensitivity Study in Children: A Question of Ethics
The abstract presented for a paper by Yang, Felsen and Poppas “Nerve Sparing Ventral Clitoroplasty: Analysis of Clitoral Sensitivity and Viability” in the October 2007 Journal of Urology sounds rather cut and dry:
“Purpose Enlargement of the clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia and other disorders of sexual development. Controversy persists regarding the viability and sensitivity of the clitoris following clitoroplasty. We present 51 consecutive cases of nerve sparing ventral clitoroplasty performed by a single surgeon. Materials and Methods Nerve sparing ventral clitoroplasty was performed in all patients. Postoperative evaluation for clitoral viability included gross examination and capillary perfusion testing. Patients older than 5 years were evaluated for clitoral sensory testing and vibratory sensory testing. Results A total of 51 patients 4 months to 24 years old (mean age ± SD 4.6 ± 6.8 years) with clitorimegaly underwent nerve sparing ventral clitoroplasty. Of the patients 41 had capillary perfusion testing of the clitoris, of whom all had a viable clitoris. Ten of the 41 patients underwent clitoral sensory testing. Patients reported an average degree of sensation of 3.6 ± 0.9 at the labia minora and 4.8 ± 0.4 at the clitoris. Nine of the 10 patients also underwent vibratory sensory testing. Average values for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08, and 5.83, respectively. Mean time after surgery for the patients who underwent clitoral sensory testing/vibratory sensory testing was 2.0 ± 0.8 years. No variations in the sensitivity results were reported at followup in 2 patients. Conclusions To our knowledge this is the largest report of followup testing of clitoral viability and sensation after clitoroplasty. Continued long-term followup is ongoing to document long-term sexual function using this nerve sparing ventral approach for clitoroplasty. “
And ends with “study received medical institution review board approval.”
However, ethicists Alice Dreger and Ellen K. Feder writing “Bad Vibrations” 6-16-2010 in the on-line Hastings Center Bioethics Forum consider along with others including surgeons surgery to reduce the size of a large clitoris as medically unnecessary but their main concern with the study was expressed as follows:
“we are writing to express our shock and concern over the follow-up examination techniques described in up exams – which involve Poppas stimulating the girls’ clitorises with vibrators while the girls, aged six and older, are conscious – we were so stunned that we did not believe it until we looked up his publications ourselves. Here more specifically is, apparently, what is happening: At annual visits after the surgery, while a parent watches, Poppas touches the daughter’s surgically shortened clitoris with a cotton-tip applicator and/or with a “vibratory device,” and the girl is asked to report to Poppas how strongly she feels him touching her clitoris. Using the vibrator, he also touches her on her inner thigh, her labia minora, and the introitus of her vagina, asking her to report, on a scale of 0 (no sensation) to 5 (maximum), how strongly she feels the touch. Yang, Felsen, and Poppas also report a “capillary perfusion testing,” which means a physician or nurse pushes a finger nail on the girl’s clitoris to see if the blood goes away and comes back, a sign of healthy tissue. Poppas has indicated in this article and elsewhere that ideally he seeks to conduct annual exams with these girls. He intends to chart the development of their sexual sensation over time.”
The ethicists concerns was not that this genital testing would provide general knowledge about sensory complications of the specific surgical technique but “but it isn’t clear to us how this kind of genital touching post-operatively is in individual patients’ best interests.” So it appears that the view presented is that the surgery is unnecessary in the first place and the repeated post-operative testing is not for the benefit of the patients. What may set this study apart from studies regarding sensation over other parts of the body? Is it because one might look at the testing as a potentially sexual experience for an innocent girl and potentially psychologically harmful? Is such a study ethical? Read the full Bioethics Forum commentary at the link above and let me know if you consider that the authors’ view hold merit. ..Maurice.