21) Most individuals are convinced by the age of 10-15 as to the direction that would be most suitable for them; male or female. Some decisions, however, should be stalled as long as possible to increase the likelihood that the individual has some experience with which to judge. For instance, a female with a phallic clitoris, sexually inexperienced with partner or masturbation, may not realize the loss in genital sensitivity and responsivity that can accompany cosmetic clitoral reduction. Insure that sufficient information is provided to aid in any decision.

22) Most intersex conditions can remain without any surgery at all. A woman with a phallus can enjoy her hypertrophied clitoris and so can her partner. Women with the androgen insensitivity syndrome or virilizing congenital adrenal hyperplasia who have smaller than usual vaginas can be advised to use pressure dilation to fashion one to facilitate coitus; a woman with partial A.I.S. likewise can enjoy a large clitoris. A male with hypospadias might have to sit to urinate without mishap but can function sexually without surgery. An individual with a micropenis can satisfy a partner and father children.

There is disagreement as to whether gonads that might prove masculinizing or feminizing at puberty should be removed early on to prevent such changes in a child that does not desire such changes. The disagreement involves the concept that the individual faced with such changes might actually come to prefer them to the habitus of rearing but will only become aware of them post hoc. Our bias is to leave them in so any genetic-endocrine predisposition imposed prenatally can come to be activated with puberty. We admit, however, there is no good body of clinical data from which the best prognosis can be made in such cases. There are some indications, however, that even without the onads the adrenals might prod pubertal changes.

23) If a gender change is being considered, have the individual experience a real-life living test (see e.g., [13, 14] ). In this way the individual will have first hand experience in how it actually is to live in the other role. Experience has shown that most indeed make the switch permanent but some return to their original sex of rearing. Some, usually as adults, will accept an identity as an intersex and plot their own course.

24) Maintain accurate medical, surgical, and psychotherapy records of all aspects of each case. This will facilitate whatever treatment is needed and assist in future research to enhance management of subsequent intersex cases. These records should be available to the patient.

Whenever possible, long term follow-up evaluations, e.g., at 5, 10, 15, and even 20 years of age, should become part of the record.

25) Last, we believe we have to be "authorities" in providing information and advice to the best of our ability yet not be "authoritarian" in our actions. We must allow the postpubertal individual time to consider, reflect, discuss and evaluate and then, have the last word in his or her genital modification and gender role and final sex assignment.

FINAL COMMENT

We are often asked about those intersexed individuals that have had early surgery of one sort or another, or even sex reassignment, and gone on to be happy and lead successful lives. Doesn't that demonstrate the wisdom of past practices? Our response: Humans can be immensely strong and adaptable. Certainly some intersexed individuals can, in dignity, maintain themselves in a manner that they neither would have chosen nor in which they feel comfortable -- as have others with a life condition from birth that cannot be changed (from cleft palate to meningomyelocele).

Many can adjust to surgery and reassignment for which they were not consulted and many have learned to accept secrecy, misrepresentations, white and black lies and loneliness.

People make life accommodations every day and try to better their lot for tomorrow.

We are aware of individuals that have come to terms with their life regardless of how stressed or painful. To them we offer our praise and admiration for their fortitude, strength and courage. Similarly we do the same for those that have rebelled against their circumstances and changed their lives with elective sex reassignment, surgery or whatever [15].

However, unlike individuals who have been given neonatal surgery for cleft palate or meningomyelocele, many of those who have had genital surgery or been sex reassigned neonatally have complained bitterly of the treatment. Some have sex reassigned themselves. Others treated similarly have reasons not to make an issue of the matter but are living in silent despair but coping.

The suggestions and guidelines we present are an attempt to consider ways to better life and adjustment for those intersexed and genitally traumatized persons still battling with these issues and for those yet to come.

Milton Diamond, Ph.D., is Director of the Pacific Center for Sex and Society, University of Hawaii at Manoa, John A. Burns School of Medicine, Department of Anatomy and Reproductive Biology, 1951 East-West Road Honolulu, HI 96822