It's no longer standard in pediatrics to turn a baby with a small penis into a girl, but there are lots of areas of health care where good intentions pave the way for scientifically-questionable medical procedures.

The internationally-syndicated sex-advice columnist Dan Savage recently asked me to help out with a reader who thought he had a small penis and was considering “enhancement” surgery or pills. As a consequence, I’ve gotten a bunch of mail from guys with penis size questions or comments. A man I’ll call Bob wrote to say this:

“I am one of the people with extreme small [penis] size but am proof it doesn’t cause problems if you learn to work with it. I have 3 grown children now and am happily married. We are all given many differences in life and how we deal with them is what makes the difference. Keep sending the messages ... your work is important.”

When I wrote Bob to thank him for his mail and to ask him if I could quote him, he followed-up:

For many years, the standard of care in pediatrics was to take boys born with very small penises and make them into girls: castrate them, turn their penises into “clitorises,” fashion their scrotum into labia, make a “neovagina” out of skin and/or colon.

“Absolutely feel free ... just don’t use my name ... One can be a good lover/partner if they understand what optional ways to bring pleasure are. I am also living proof that people with small penises can father children, have had multiple lovers in my life, and no complaints. Keep up your good work. The message is simple: Use what you have wisely, love yourself and your partners, and embrace diversity.”

For many years, the standard of care in pediatrics was to take boys born with very small penises (less than one-inch stretched at birth) and make them into girls: castrate them, turn their penises into “clitorises,” fashion their scrotum into labia, make a “neovagina” out of skin and/or colon. No, I am not making this up.

This is done much less often nowadays. (I am one of the people who helped change the practice.) But what bothers me is this: There never was any good evidence that a guy with a small penis couldn’t function as a boy or a man. The sex reassignments done on boys with “micropenis” were done for a vague quasi-Freudian notion that you couldn’t be a successful guy with a little one. There was absolutely no evidence that boys with small penises turned out to have female identities.

Meanwhile there was, here and there, pretty good evidence you could do OK as a boy with a small penis. (Take a look at the FAQ I wrote for ISNA on this.) But that was ignored.

OK, so maybe the doctors doing sex reassignments on boys with small penises just didn’t know the literature. But why didn’t they?

Moreover, they’re still doing lots of other sex “normalizing” surgeries again with no evidence of medical need for intervention. When I say to them, “Why don’t you go study the people who grew up with ‘ambiguous’ genitals, the kind you think lead to psychosocial disaster?” they say to me, “Well, those aren’t our patients.”

Hmmm. Sure seems like, before you start doing genital surgeries, it would be a good idea to know if there’s any medical need, no? Why is it that the penis in their hands weighs so much more heavily than all we could know about the real penises that are out there in the bushes, so to speak?

This isn’t just about genitals. This happens in so many other realms of health care, too. Lots of good intentions paving the way for lots of scientifically-questionable medical procedures. The medical treatment of birth is full of procedures (like prenatal sonograms in low-risk pregnancies, automatic continuous fetal monitoring, and routine episiotomies) done with no evidence of medical need.

Meanwhile, as David Sandberg of the University of Michigan has documented so well, the use of human growth hormone for short kids is frequently done with no evidence of medical need. (Check out David’s article in the third issue of Atrium for a nice summary. It starts on page 13.)

Why is the burden of proof landing on the patient? Shouldn’t it be on the person suggesting the intervention? Shouldn’t they have to show a genuine risk exists and that the risk can be minimized by the intervention proposed before they offer it up as “standard of care”?

Carpe datum.

This post was first published on the author’s personal website on November 7, 2007. It is republished here with permission.