New International Consensus Calls for Healthcare Providers to Stop Performing Medically Unnecessary Genital Surgeries in Prepubertal Children and Infants, Regardless of Sex or Gender
A new study led by researchers at the University of Oxford’s Uehiro Centre for Practical Ethics published today in the American Journal of Bioethics argues that all children (defined in the study as prepubertal minors) should be equally protected from medically unnecessary, non-voluntary genital cutting or surgery performed by healthcare providers – including children born with intersex traits.
According to the study, intersex traits are anatomical variations in sexual or reproductive anatomy caused by developmental differences in some children.
Corresponding author Brian D. Earp, PhD, Senior Research Fellow in the Oxford Uehiro Centre for Practical Ethics, stated: “Unless there is a physical health emergency requiring immediate intervention, no child – regardless of their sex or gender – should be forced to undergo a non-voluntary genital surgery by a healthcare provider, even if the provider has good intentions. Parents requesting such procedures for their children should be helped to explore nonsurgical alternatives.”
Key findings from the study, which does not address surgeries performed in adolescence or adulthood, include:
- Medically unnecessary genital surgeries imposed on prepubertal children and infants violate their right to bodily integrity and future sexual autonomy, regardless of the level of harm or benefit as judged by others, such as doctors or parents.
- Current policies inconsistently protect some children (e.g., those with female-typical genitalia) while allowing medically unnecessary, non-voluntary genital procedures on other children (e.g., those with intersex traits, whether assigned female or male).
- The concept of ‘medical necessity’ should be strictly defined to prevent misuse. The authors provide a definition that focuses on serious, time-sensitive physical health threats to justify non-voluntary surgeries, while arguing that broader personal needs and preferences might justify voluntary surgeries that an individual requests for themselves.
The study, authored by an international team of experts from more than two dozen countries and six continents, critically examines recent policy changes at major U.S. hospitals – including Boston Children’s Hospital and Lurie Children’s Hospital of Chicago – regarding so-called “normalising” surgeries on children with intersex traits.
The researchers identified that in recent years, both Boston and Lurie Children’s hospitals pledged to stop performing such surgeries out of respect for the bodily integrity of the child, and also to protect their future right to make certain personal decisions about their private anatomy. According to the study, these policy changes followed years of activism and protest by intersex people and their allies.
The Intersex pride flag, courtesy Intersex Human Rights Australia
The study argues that these surgeries are not necessary for, and risk harming, the individual’s physical and mental health, aiming instead to fit the child’s body into a narrow gender binary, which opponents argue is a violation of human rights unless chosen by the individual themselves.
When performed on young children who have not yet entered puberty and cannot consent on their own behalf, genital surgery must be urgently necessary to preserve the physical health of the child in order for it to be ethical, according to the article.
In addition to “normalising” surgeries on infants with intersex traits, the study critiques other medically unnecessary practices sometimes performed on prepubertal children by licensed healthcare providers at the request of parents, including “ritual pricking” or other “symbolic” cutting of young girls’ vulvas for sociocultural purposes (defined as “medicalised FGM” by the World Health Organisation) and “routine” newborn penile circumcision performed for non-religious reasons, a medicalised birth custom in the United States.
“Everyone should have the same right to decide what happens to their own sexual anatomy, no matter their skin colour or the size or shape of their genitals”
Corresponding author Brian D. Earp
The article does not evaluate religious circumcision, noting that practices done for religious reasons may raise distinctive legal and ethical issues.
The study also identifies important developments internationally, including the enactment of legislative protections for children with intersex traits in a small but growing number of jurisdictions, primarily in Europe and Australia.
While the authors explicitly avoid making any legal recommendations and do not call for criminalisation of intersex surgeries, they argue that the same underlying ethical principles should be consistently applied to all children, whether or not they have intersex traits.
The paper calls for major policy changes, urging medical associations and hospitals to “publicly commit to stop performing — or allowing — any medically unnecessary, non-voluntary genital cutting or surgery on children [defined as pre-pubescent minors] within their care, irrespective of the child’s sex characteristics.”
This study provides a comprehensive ethical framework for addressing a complex and sensitive issue, challenging medical professionals and policymakers to reconsider current practices and ensure equal protection for all individuals.
“Everyone should have the same right to decide what happens to their own sexual anatomy, no matter their skin colour or the size or shape of their genitals,” stated corresponding author Brian D. Earp.
Notes to editors:
For further information or interviews: Contact the corresponding author: Brian D. Earp, PhD, Oxford Uehiro Centre for Practical Ethics, University of Oxford, and Centre for Biomedical Ethics, National University of Singapore: brian.earp@philosophy.ox.ac.uk (until October 1, 2024) or bdearp@nus.edu.sg (after October 1, 2024).
About the Oxford Uehiro Centre for Practical Ethics. The goal of the Centre is to encourage and support debate and deeper rational reflection on practical ethics. The Centre as a whole will not promote a particular philosophy, approach, solution or point of view, though its individual members may give an argument to a substantive conclusion as a basis for dialogue, engagement and reflection. It is the method of rational analytic practical ethics that we aim to advance. The vision is Socratic, not missionary. We seek to be inclusive, encouraging debate between different approaches to ethics, aiming to resolve disagreements and identifying key areas of consensus. Practical ethics should not only advance knowledge by deeper, rational ethical reflection and dialogue, it should change people’s hearts and so better their own lives and the lives of others.
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