Commentary to 'Practice changes in childhood surgery for ambiguous genitalia?'.
Treating children is treating future adults. And for a large part of our reconstructive surgery, reliable results concerning final cosmesis and function can only be assessed when the child has grown up to become an adolescent or a young adult. Only recently have we been seeing reports showing substantial long-term results of our early surgery. And we need more reports from teams like this one, who have vast experience in transitioning to adult care [1]. In this report, the authors set out to compare two cohorts of adolescent girls born with ambiguous genitalia in order to identify differences in outcome that could reflect changes in practice. This was done in the wake of the 2006 consensus statement on the management of intersex disorder, which advocated a more cautious attitude towards feminising surgery. Although a decade separates both cohorts, the 2012 cohort underwent their surgery well before the consensus statements, so one could hardly expect attitudes to have changed dramatically. In this respect, it will be interesting to see the results of children born after 2006. However, as the authors have stated, further evidence from surveys of current practice show that even nowadays, the 2006 recommendations are rarely followed. The authors have standardised their evaluation, which is a crucial step in the quest to bring scientifically valid information to what remains a controversial and sometimes passionate subject. And although it is unfortunate that for the recent cohort, we do not have results of clitoral sensitivity, one of the more debated aspects of feminising surgery, it is interesting to note that the results of the vaginoplasties show slight improvement between both groups. The authors question why there is such reticence to change, given the caution recommended by practice guidelines and the substantial evidence of relatively poor outcome. This is a very good question. Obviously, part of the answer lies in the fact that many paediatric surgeons believe leaving ambiguous genitals unaltered would be unbearable for patients and families, although it is fair to say that, in the absence of clear evidence, this remains an assumption. And I suppose one could argue that paediatric surgeons are influenced by the fact that they deal more often with the child’s parents than with the adult the child becomes. In that respect, we must gather more evidence about how children, who do not undergo feminising surgery and their families, cope during childhood and adolescence. But the answer might also partly reside in the time scale between the initial surgery and its evaluation. Indeed, we are seeing the results of surgery performed 10 or 15 years ago.We are evaluating the past, and even when results are disappointing, we tend to believe that in the meantime we have improved. And it is true.We do improve, and because of what we learn,whatwearedoing today isbetter thanwhatwewere doing 15 years ago, as this report also indicates. Do the criticisms of yesterday’s surgery still hold true today? Therein residesoneof the keydifficulties of our trade,which is thatwe areoftenevaluatingpracticeswhichhave sinceevolved.What we have yet to do, is determine with the help of longitudinal studies, reliable early markers of future results, that is the true relationship between shortand long-term results.