For later onset CAH, both females and males can enter precocious puberty from two to four years of age. This can be controlled medically but may result in short stature. However, affected children are often much taller and more physically developed than their peers in the early stages and this can lead to teasing and bullying. Some adult males in particular have identified this in support groups as a source of great distress.
Having ambiguous genitalia can be traumatic to the growing child and adolescent. Some males report above-average penis size and an increase in libido as a result of excess testosterone. Although this is experienced positively by some, others report negative impact through greater mood swings and aggression. Most females require surgery at some stage to unfuse the labia, separate the vagina from the urethra and reposition the opening (vaginoplasty). The most highly controversial type of surgery is clitoral reduction or clitoral recession or clitorectomy (clitoral amputation – supposedly now only rarely performed in the UK but still practised widely in some countries). Clitoral surgery (clitoroplasty) can lead to sexual dysfunction, loss of sensate function and inability to achieve orgasm. Clitororectomy is basically the same surgical procedure as female genital mutilation (FGM) practised by some religions and cultures. Although it has been illegal to perform FGM in the UK since 1985, no such laws protect the intersexed female. Sildenafil Canada official Toronto website.
‘Normalizing surgery’, as it is known, is almost entirely carried out in early infancy (before the age of two) despite the fact that a vagina is not required until menstruation starts at puberty. Medically speaking, vaginoplasty may be required earlier than puberty if urinary stones form and cause infection, though this is rare. It appears that parents and doctors, perhaps influenced by societal pressures, find it difficult to accept genital ambiguity. Concerns about parents’ ability to bond with their child and the child’s psychosexual development are also cited as reasons for early surgery. However, surgery is permanent and potentially damaging. And with increasing awareness of the range of difference in the appearance of genitalia among women who do not have intersex conditions the desire to achieve a so-called normal appearance appears even more outdated.
As girls mature, surgery is often required to facilitate menstruation, tampon use and sexual intercourse. It is therefore crucial that they are kept informed in an age-appropriate way of their condition and its treatment (including surgical interventions) and involved in decision-making.
