It is possible to surgically create near normal looking external genitalia and a vagina suitable for sexual intercourse without much financial burden in free government tertiary teaching hospitals of most of the metropolitan cities. The whole idea of gender re- assignment and gonadectomy at birth is to avoid the social problems and brain imprinting with testosterone. Of course, she would not mensturate or concieve, similar to any female subject having undergone hysterectomy for medical reasons. Such patients need counselling close to puberty; it could be very disturbing for a female child not to attain menarche. She does not have to take hormones life long. Once she has achieved a reasonably accepted height, she could be started on estrogen therapy for few months that would help her to develop breasts like normal girls. And this hormonal therapy is cheap.

It is obvious that Dr. Tiwari, like many others, does not appreciate the social, psychological, behavioral implications for a boy with aphalia. I agree that in most Indian villages and towns, it would be easier to live as a sexually incompetent male in society rather than a single unmarried girl. But things are improving slowly. She does not, necessarily have to get married. She could study and establish herself professionally and live single. And even if chooses to get married, she could enjoy sex; her male sexual partner could have enjoyable sexual intercourse. I have patients who had undergone vaginoplasty for uterovaginal agenesis and who are happily married!

The message that I wanted to convey was that gender re-assignment is feasible but it is acceptable only when it is offered at birth. Situation is no different in this regard even in the western countries. It becomes a very difficult issue when the child has been raised as a boy for few years and brain imprinting with testosterone has already taken place.

Y.K. Sarin,
Department of Pediatric Surgery,
Maulana Azad Medical College,
New Delhi-110 002, India.
Email: [email protected]