Degree of genital ambiguity is commonly measured by thePrader classification,[6] which ranges, in ascending order of masculinisation, from1:female external genitalia with clitoromegaly through5:pseudo-phallus looking like normal male external genitalia.[7]
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 receivednorethisterone during pregnancy, masculinization of the fetus occurs, resulting in hypertrophy of the clitoris;[8] however, this is rarely seen nowadays due to use of saferprogestogens. It can also be caused by theautosomalrecessive congenital disorder known asFraser syndrome.[9]
In acquired clitoromegaly, the main cause is endocrine hormonal imbalance affecting the adult person, includingpolycystic ovarian syndrome (PCOS)[10] andhyperthecosis. Acquired clitoromegaly may also be caused by pathologies affecting the ovaries and otherendocrine glands. These pathologies may include virulent (such asarrhenoblastoma) andneurofibromatosic tumors.[11] Another cause is clitoral cysts.[12] Sometimes there may be no obvious clinical or hormonal reason.[2]
Female bodybuilders and athletes who useandrogens, primarily toenhance muscular growth, strength and appearance, may also experience clearly evident enlargement of the clitoris and increases inlibido.[13][14] Women who use testosterone for therapeutic reasons (treating low libido, avertingosteoporosis, 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.
InAtlas of Human Sex Anatomy (1949) byRobert Latou Dickinson, thetypical 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 anaverage sized clitoris.[16]
Early surgical reduction of clitoromegaly via full or partialclitoridectomy is controversial, as many that have undergone 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 aftertestosterone testing revealed that they had5α-Reductase 2 deficiency.[22][23] In April 2016, theUnited Nations Special Rapporteur on health, Dainius Pūras, condemned this treatment as a form offemale genital mutilation "in the absence of symptoms or health issues warranting those procedures."[24]
^Meyer WJ, Webb A, Stuart CA, Finkelstein JW, Lawrence B, Walker PA (April 1986). "Physical and hormonal evaluation of transsexual patients: a longitudinal study".Archives of Sexual Behavior.15 (2):121–38.doi:10.1007/BF01542220.PMID3013122.S2CID42786642.
^PRADER A (July 1954). "Der genitalbefund beim Pseudohermaproditismus femininus des kongenitalen adrenogenitalen Syndroms. Morphologie, Hausfigkeit, Entwicklung und Vererbung der verschiedenen Genitalformen" [Genital findings in the female pseudo-hermaphroditism of the congenital adrenogenital syndrome; morphology, frequency, development and heredity of the different genital forms].Helvetica Paediatrica Acta (in German).9 (3):231–48.PMID13201003.
^van Haelst MM, Scambler PJ, Hennekam RC (December 2007). "Fraser syndrome: a clinical study of 59 cases and evaluation of diagnostic criteria".American Journal of Medical Genetics Part A.143A (24):3194–203.doi:10.1002/ajmg.a.31951.PMID18000968.S2CID25053508.
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