Documented involvement of social work in relation to people with variations in sex characteristics is sparse. This commentary reflects what is known about the role of social workers according to current care guidelines and existing research. We foreground social justice advocacy as important for this community, and suggest how social workers (could better) work with people with variations in sex characteristics. We engage the concept of ‘intersex justice’ and highlight opportunities for social workers to impact at the levels of policy and social work training as well as impacting on how health services meet individuals with variations in sex characteristics.

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between <i>voluntary</i> and <i>nonvoluntary</i> procedures and focus on <i>nonvoluntary</i> procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform <i>any</i> nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a <i>nonvoluntary</i> genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that <i>voluntary</i> surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

This Special Issue showcases the expanding body of international scholarly work within intersex studies [...]

According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts.

Human rights organisations raise concerns about medical interventions on children with intersex variations, particularly when these interventions impinge on the child’s bodily autonomy and are without a sound biomedical basis. Psychosocial literature and legal literature have made very different contributions to thinking about the healthcare of people with intersex variations, but both literatures pay attention to the process of informing patients about elective interventions and the workings of consent. The present paper addresses the absence of dialogue across medical, legal, and psychosocial literatures on the surgical treatment of children with intersex variations. The analysis presented in this paper focusses on the assumptions underpinning the practice of allowing parents to consent on behalf of their children to elective surgery in the instance of hypospadias. In this paper, we (i) introduce consent from a medico-legal perspective, (ii) analyse selected documents (including medical, psychosocial, and human rights documents) in relation to the concept of parental consent on behalf of a child, and (iii) reconsider the current practice of inviting parents to give consent for elective genital surgery on infants. What emerges from our analysis is a picture of long-term relationships and interactions over time within which the consent process is located. The focus is not whether consent is granted, but whether free and informed consent is granted. This picture allows us to expand the understanding of “informed consent,” highlighting the importance of producing ethical interactions between health professionals and patients with the view that these relationships last for years. Understanding consent as a process, considering information as dynamic, partial, and negotiated, and understanding the doctor–patient interaction as relational might enable us to imagine the kind of informed consent process that genuinely works for everyone concerned. Our examination of selected legal, medical, and psychosocial texts raises doubt about whether current hospital practice meets the requirement of informed parental consent on behalf of children undergoing hypospadias surgery.

There are many different variations in sex characteristics, some of which have implications for how the body goes through puberty. This paper draws from critical disability studies and childhood and youth studies to understand the teenage experiences and aspirations of young people with variations in sex characteristics, focusing particularly on navigating puberty. We undertook a reflexive thematic analysis with interview data from 12 young people in England, all assigned female at birth. Our analysis produced a central theme: aspiring to certainty through “fixing” the wrong kind of puberty. Participants experience puberty as a time where things exist on a continuum of rightness and wrongness in comparison with their peers and in relation to their specific variation. We suggest that the neoliberal aspiration to and illusion of bodily control and certainty provides the context within which the medical management of variations in sex characteristics makes sense. Going through medical intervention in relation to a variation in sex characteristics provides a very particular aspirational context for young people. The experience of puberty is intersectionally differentiated for young people with variations in sex characteristics.

Medical intervention in the context of variations in sex characteristics (intersex variations) has been addressed by many academic disciplines, including medical research, human rights law, and psychosocial research, but few studies bring these diverse disciplines into substantive dialogue. Recent years have seen an increase in human rights statements about the indefensibility of some surgical interventions carried out on children with variations in sex characteristics. This has prompted attempts in some jurisdictions to move towards human rights-based healthcare for people with intersex variations. Such a move will require better dialogue across legal and health-related disciplines, as well as a clearer overview of which and how many surgical interventions are at issue. The present paper initiates the dialogue across disciplines and quantifies surgical interventions carried out on the sexual and reproductive organs of minors in Aotearoa New Zealand, over a five-year period. We suggest that, for the purpose of monitoring any shift towards human rights-based healthcare, national healthcare data will need to more clearly identify diagnoses and interventions relating to minors with variations in sex characteristics.

The UN Committee on the Rights of the Child has recommended that Aotearoa New Zealand ban unnecessary and unconsented surgery on intersex children. Yet, the overall number of surgeries being undertaken on the genital and reproductive organs of children remains largely unchanged. Neither is it clear how many surgeries were undertaken on intersex children and what information and explanations were given to children and their families as to why the surgery was necessary. Culturally sensitive, medical, psychosocial and legal research must inform decision-making around surgical interventions on children with variations in sex characteristics, in order to realise the rights of intersex children in Aotearoa New Zealand.

Introduction: Over the past two decades, there has been a shift from concealing diagnoses of sex development from impacted people to the broad principle of age-appropriate disclosure. This change is consistent with children's rights and with general shifts towards giving children medical information and involving patients in medical decision-making. The present paper examines how health professionals, young people and caregivers with experience in this area talk about the process of telling children about a diagnosis relating to sex development. The focus is on (i) who is given the role of talking with children and young people about their medical condition and care in the context of a diagnosis relating to sex development and (ii) what strategies seem to work, and what dilemmas are encountered, in engaging children and young people in talk about their condition and healthcare. Method: Qualitative semi-structured interviews were carried out with 32 health professionals, 28 caregivers and 12 young persons recruited in the UK and Sweden, and thematic analysis was undertaken. Results: The analysis identifies strategies and dilemmas in communication and a widespread assumption that it is caregivers' responsibility to talk with children<b>/</b>young people about the diagnosis. This assumption creates difficulties for all three parties. This paper raises concern about children<b>/</b>young people who, despite a more patient-centred care ethos, are nevertheless growing up with limited opportunities to learn to talk about intersex or differences in sex development with confidence. Discussion: Learning to talk about this topic is one step towards shared decision-making in healthcare. A case is made for services to take clearer responsibility for developing a protocol for educating children and young people in ways that involve caregivers. Such a process would include relevant medical information as well as opportunities to explore preferred language and meaning and address concerns of living well with bodily differences.

In this commentary, we examine the role of non-Indigenous psychology researchers in settler states such as Aotearoa / New Zealand. A key focus is on demedicalising and decolonising intersex. We describe approaches to knowledge production that are based on the decolonising thinking of Indigenous and non-Indigenous researchers, and that open up opportunities for resistance and transformation. We then examine how decolonisation can be brought into dialogue with demedicalisation. Finally, we consider opportunities for an Indigenous understanding of health to contribute to the demedicalising aspirations of intersex advocates and researchers.

This paper builds an argument about genital surgery in the context of medical treatment of children and young people with variations in sex characteristics. First, I set out what is known from existing research including psychological research, surgical follow-up studies and parental regret studies. Second, I present an analysis of surgeons’ talk about children, young people and parents in relation to genital surgery. This paper focuses most specifically on hypospadias surgery, but the argumentation is relevant for other kinds of genital surgery carried out in the context of genital variations. The questions guiding this paper are: what research evidence supports hypospadias surgery and what research evidence brings this surgery into question? How might a new interpretation of the evidence, in light of psychosocial research and human rights concerns, contribute to a new perspective on elective genital surgery on minors with variations in sex characteristics? I draw out implications for clinicians supporting parents to decide whether a surgical pathway is the best option for their child.

Classrooms are important spaces for young people with variations in sex characteristics and their classmates. Sex education can promote agency and well-being by helping young people make sense of their embodiment and form rewarding social relationships and by changing societal understandings about variations in sex characteristics. Realising this potential however may hinge on how sex education makes intersex (un)talkable. We draw on interviews with 22 young people on how and why they try to make their variation in sex characteristics talkable with others. By focusing on how they talk to others and why they do not talk to others, this research highlights how participants ‘fear rejection’ but need to talk to others about their variation in the process of ‘dealing with it’. Participants also struggle with ‘secrecy versus privacy’ and how to ‘communicate strategically.’ Findings acknowledge the emotional work required of people with variations in sex characteristics when making intersex talkable. The analysis points to the role of both talking and silence. We conclude by envisaging a norm-critical sex education that engages with the responsibilities of both talking and listening, shifting the burden away from individual young people with variations in sex characteristics and working towards more mutual social relationships.

Abstract This chapter takes a critical psychology approach to reviewing research on psychological distress among people with variations of sex characteristics. The focus is on depathologizing emotional distress and developing affirming and empowering approaches to healthcare. Affirming approaches to psychosocial healthcare can be undertaken by health professionals who have enough knowledge about intersex, diverse sex development, or variations of sex characteristics to be able to support positive adaptation to bodily variation and facilitate non-stigmatizing talk about the experience of living with a diagnosis. There is room for significant development here, particularly research addressing psychosocial well-being in ways that are non-medicalized and culturally relevant in diverse global regions.