| Clitoromegaly | |
|---|---|
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| A person with clitoromegaly | |
| Specialty | Gynaecology  |
Clitoromegaly (or macroclitoris) [1] is an abnormal enlargement of the clitoris that is mostly congenital; it is otherwise acquired through deliberately induced clitoral enlargement e.g. body modification by use of anabolic steroids, including testosterone. [2] [3] [4] [5] It can happen as part of a gender transition. It is clinically distinguishable from normal enlargement of the clitoris seen during sexual arousal.
Degree of genital ambiguity is commonly measured by the Prader classification, [6] which ranges, in ascending order of masculinisation, from 1: female external genitalia with clitoromegaly through 5: pseudo-phallus looking like normal male external genitalia. [7] [ dead link ]
Clitoromegaly is a rare condition and can be either present by birth or acquired later in life. If present at birth, congenital adrenal hyperplasia can be one of the causes, since in this condition the adrenal gland of the female fetus produces additional androgens and the newborn baby has ambiguous genitalia which are not clearly male or female. In pregnant women who received norethisterone during pregnancy, masculinization of the fetus occurs, resulting in hypertrophy of the clitoris; [8] however, this is rarely seen nowadays due to use of safer progestogens. It can also be caused by the autosomal recessive congenital disorder known as Fraser syndrome. [9]
In acquired clitoromegaly, the main cause is endocrine hormonal imbalance affecting the adult person, including polycystic ovarian syndrome (PCOS) [10] and hyperthecosis. Acquired clitoromegaly may also be caused by pathologies affecting the ovaries and other endocrine glands. These pathologies may include virulent (such as arrhenoblastoma) and neurofibromatosic tumors. [11] Another cause is clitoral cysts. [12] Sometimes there may be no obvious clinical or hormonal reason. [2]
Female bodybuilders and athletes who use androgens, primarily to enhance muscular growth, strength and appearance, may also experience clearly evident enlargement of the clitoris and increases in libido. [13] [14] Women who use testosterone for therapeutic reasons (treating low libido, averting osteoporosis, as part of an anti-depressant regimen, etc.) may experience some enlargement of the clitoris, although the dosages warranted for these conditions are much lower.
In Atlas of Human Sex Anatomy (1949) by Robert Latou Dickinson, the typical clitoris is defined as having a crosswise measurement of 3 to 4 mm (0.12 - 0.16 inches) and a lengthwise measurement of 4 to 5 mm (0.16 - 0.20 inches). [15] On the other hand, in obstetrics and gynecology medical literature, a frequent definition of clitoromegaly is when there is a clitoral index (product of lengthwise and crosswise measurements) of greater than 35 mm2 (0.05 inches2), which is almost twice the size given above for an average sized clitoris. [16]
Early surgical reduction of clitoromegaly via full or partial clitoridectomy is controversial, and intersex people exposed to such treatment have spoken of their loss of physical sensation, and loss of autonomy. [17] [18] In recent years, human rights institutions have criticized early surgical management of such characteristics. [19] [20] [21]
In 2013, it was disclosed in a medical journal that four unnamed elite female athletes from developing countries were required to receive gonadectomies and partial clitoridectomies if they wanted to continue competing after testosterone testing revealed that they had an intersex condition. [22] [23] In April 2016, the United Nations Special Rapporteur on health, Dainius Pūras, condemned this treatment as a form of female genital mutilation "in the absence of symptoms or health issues warranting those procedures." [24]
In amniotes, the clitoris is a female sex organ. In humans, it is the vulva's most erogenous area and generally the primary anatomical source of female sexual pleasure. The clitoris is a complex structure, and its size and sensitivity can vary. The visible portion, the glans, of the clitoris is typically roughly the size and shape of a pea and is estimated to have at least 8,000 nerve endings.
Clitoridectomy or clitorectomy is the surgical removal, reduction, or partial removal of the clitoris. It is rarely used as a therapeutic medical procedure, such as when cancer has developed in or spread to the clitoris. Commonly, non-medical removal of the clitoris is performed during female genital mutilation.
In female humans and other mammals, the clitoral hood is a fold of skin that surrounds and protects the glans of the clitoris; it also covers the external clitoral shaft, develops as part of the labia minora and is homologous with the foreskin in the male reproductive system. The clitoral hood is composed of mucocutaneous tissues; these tissues are between the mucous membrane and the skin, and they may have immunological importance because they may be a point of entry of mucosal vaccines.
Virilization or masculinization is the biological development of adult male characteristics in young males or females. Most of the changes of virilization are produced by androgens.
Sex assignment is the discernment of an infant's sex, typically made at birth based on an examination of the baby's external genitalia by a healthcare provider such as a midwife, nurse, or physician. In the vast majority of cases (99.95%), sex is assigned unambiguously at birth. However, in about 1 in 2000 births, the baby's genitalia may not clearly indicate male or female, necessitating additional diagnostic steps, and deferring sex assignment.
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is a genetic disorder characterized by impaired production of cortisol in the adrenal glands.
Intersex medical interventions (IMI), sometimes known as intersex genital mutilations (IGM), are surgical, hormonal and other medical interventions performed to modify atypical or ambiguous genitalia and other sex characteristics, primarily for the purposes of making a person's appearance more typical and to reduce the likelihood of future problems. The history of intersex surgery has been characterized by controversy due to reports that surgery can compromise sexual function and sensation, and create lifelong health issues. The medical interventions can be for a variety of reasons, due to the enormous variety of the disorders of sex development. Some disorders, such as salt-wasting disorder, can be life-threatening if left untreated.
The history of intersex surgery is intertwined with the development of the specialities of pediatric surgery, pediatric urology, and pediatric endocrinology, with our increasingly refined understanding of sexual differentiation, with the development of political advocacy groups united by a human qualified analysis, and in the last decade by doubts as to efficacy, and controversy over when and even whether some procedures should be performed.
Maternal use of androgens or high doses of certain weakly androgenic synthetic progestogens (progestins) structurally related to testosterone can masculinize (virilize) the vulva of a female fetus during susceptible times in pregnancy.
Partial androgen insensitivity syndrome (PAIS) is a condition that results in the partial inability of the cell to respond to androgens. It is an X linked recessive condition. The partial unresponsiveness of the cell to the presence of androgenic hormones impairs the masculinization of male genitalia in the developing fetus, as well as the development of male secondary sexual characteristics at puberty, but does not significantly impair female genital or sexual development. As such, the insensitivity to androgens is clinically significant only when it occurs in individuals with a Y chromosome. Clinical features include ambiguous genitalia at birth and primary amenhorrhoea with clitoromegaly with inguinal masses. Müllerian structures are not present in the individual.
Sexual differentiation in humans is the process of development of sex differences in humans. It is defined as the development of phenotypic structures consequent to the action of hormones produced following gonadal determination. Sexual differentiation includes development of different genitalia and the internal genital tracts and body hair plays a role in sex identification.
Clitoral enlargement methods are forms of body modification that have the potential to increase the size of the clitoris and enhance sexual pleasure. Clitoral enlargement can be accomplished through a variety of means, each potentially having certain side effects and risks.
Disorders of sex development (DSDs), also known as differences in sex development or variations in sex characteristics (VSC), are congenital conditions affecting the reproductive system, in which development of chromosomal, gonadal, or anatomical sex is atypical. DSDs is a clinical term used in some medical settings for what are otherwise referred to as intersex traits. The term was first introduced in 2006 and has not been without controversy.
Intersex people are individuals born with any of several sex characteristics, including chromosome patterns, gonads, or genitals that, according to the Office of the United Nations High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies".
The Prader scale or Prader staging, named after Andrea Prader, is a coarse rating system for the measurement of the degree of virilization of the genitalia of the human body and is similar to the Quigley scale. It primarily relates to virilization of the female genitalia in cases of congenital adrenal hyperplasia (CAH) and identifies five distinct stages, but in recent times has been used to describe the range of differentiation of genitalia, with normal infant presentation being shown on either end of the scale, female on the left (0) and male on the right (6).
Intersex people in the United Kingdom face significant gaps in legal protections, particularly in protection from non-consensual medical interventions, and protection from discrimination. Actions by intersex civil society organisations aim to eliminate unnecessary medical interventions and harmful practices, promote social acceptance, and equality in line with Council of Europe and United Nations demands. Intersex civil society organisations campaign for greater social acceptance, understanding of issues of bodily autonomy, and recognition of the human rights of intersex people.
Intersex people are born with natural variations in physical and sex characteristics including those of the chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit the typical definitions for male or female bodies". Such variations may involve genital ambiguity, and combinations of chromosomal genotype and sexual phenotype other than XY-male and XX-female. Preimplantation genetic diagnosis allows the elimination of embryos and fetuses with intersex traits and thus has an impact on discrimination against intersex people.
Late onset congenital adrenal hyperplasia (LOCAH), also known as nonclassic congenital adrenal hyperplasia, is a milder form of congenital adrenal hyperplasia (CAH), a group of autosomal recessive disorders characterized by impaired cortisol synthesis that leads to variable degrees of postnatal androgen excess.
Sexual anomalies, also known as sexual abnormalities, are a set of clinical conditions due to chromosomal, gonadal and/or genitalia variation. Individuals with congenital (inborn) discrepancy between sex chromosome, gonadal, and their internal and external genitalia are categorised as individuals with a disorder of sex development (DSD). Afterwards, if the family or individual wishes, they can partake in different management and treatment options for their conditions.
Clitoroplasty is a type of plastic surgery involving the clitoris. It encompasses several procedures, including clitoral reduction, clitoral reconstruction, and the creation of a neoclitoris in male-to-female gender-affirming surgery. These surgeries aim to retain or restore sensation and function in the clitoris, often employing nerve-sparing techniques.