Van Howe and Cold are exactly correct when they say "the most important lesson to be learned from this tragedy [was that] consent was never given by the patient." We agree totally.

For our conclusions, however, we were limiting our advice for cases similar to the one presented. In cases of a penis loss, we advised that the child continue to be raised as a boy and refer the parents and child for appropriate and long-term counseling. Be honest as to what had occurred. This conservative management requires no statement of consent.

We should have been clearer in our intimation that the long-term counselings extend until the child can cogently offer his input to surgery or sex reassignment. This should be at least until puberty has been reached and the patient has experienced conviction or doubt as to his sexual identity and has arrived at a sexual orientation (androphilic, gynecophilic, or ambiphilic).

We predict such individuals will accept their male assignment without doubt and most likely be gynecophilic. They certainly will harbor concern over their ability to function sexually without a penis, but their identity as males will be stable. And, again, the counseling becomes crucial. These boys will, after puberty, be in a better situation from which to decide the type and extent of future surgical repair they might desire. Any decision involves a trade-off of cosmetics for genital sensitivity and scarring that only they can evaluate. This advice holds also for cases of micropenis and hypospadias. Our focus did not revolve about phimosis repair or circumcision per se, nor were we involved in those decisions, so we did not comment on that.


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