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(Photo: antpkr/Shutterstock)

Do You Have to Pee Standing Up to Be a Real Man?

• February 13, 2014 • 6:00 AM

(Photo: antpkr/Shutterstock)

This simple idea, encouraged by medical texts of the past that taught deviation from the norm would lead to confused sexuality and gender identity issues, has put a surprising number of babies under the knife.

In contemporary American culture, much is still demanded of “real men”: To be commanding and composed. To be courageous and chivalrous. To be rugged, strong, and low-voiced. And to be able to pee standing up.

Males are sometimes born with a urinary meatus (what kids might call “the pee hole”) somewhere other than the tip of the penis, which can make it difficult to meet this last demand. The opening might be farther down the head, on the shaft, or even on the scrotum. When this happens, and a doctor notices it, a newborn lad gets hit with a diagnosis of hypospadias. Often, he will be referred to a surgeon for “correction.”

How many boys are born with hypospadias is a matter of some dispute. Environmental hormone disruptors—including those found in some medications for hair loss and prostate cancer—increase chances of a male fetus developing hypospadias, and so the rate of hypospadias in America is probably increasing every year. Right now, American medical textbooks put the frequency at around one in 150 to 250 live male births, which would make it pretty common. That frequency would mean that, when you’re shopping in Costco, chances are so is a man born with hypospadias. When you’re in a major sports stadium, chances are you’re surrounded by a few hundred such men.

In fact, hypospadias might be much more common than even that, and may have always been. In 1995, the Journal of Urology published a stunning—and generally ignored—study out of Germany that showed that urologists have unreasonably strict expectations for penises. These physicians looked at a group of 500 men and found that only 55 percent could be labeled “normal,” according to medical standards. Of the 500, fully 225 counted as having hypospadias.

Could it be that surgeons and parents have really worried that a child left to grow up with atypical genitals will be at greater risk of gender identity and sexual orientation “problems”?

The team observed that “it remains unclear whether the tip of the glans [penis] is truly the normal site” for the urethral opening. The physicians also questioned whether surgical “correction” of hypospadias was necessary, given what they admitted was the “significant complication rate” of “reparative” surgeries—and given these men seemed to have figured out how to use their penises to their own satisfaction.

Yet every day in America, baby boys are put under anesthesia and under the knife to “fix” hypospadias. This involves moving the meatus to where surgeons believe it’s “supposed” to be (regardless of the German study’s findings). In mild cases of hypospadias, this is often a relatively simple surgery, and most of the time comes with no complications. In more significant cases, moving the meatus involves having to surgically build more urethra (the tube that carries urine and, in males, semen). That’s when things can get especially tricky.

The risks of “hypospadias repair” surgeries include wounds opening up on the penis (fistulas), scar tissue building up inside the urethra (stenosis), chronic pain at the surgical site, and chronic infections. For some boys, surgical “repairs” to their penises turn out to be downright destructive—even devastating. Jim Lake, a 54-year-old counselor who works in the Chicago area, has had 17 major urological surgeries to try and undo the damage that followed the surgical “correction” performed on his penis when he was just a baby. The medical literature has a special name for boys and men like Jim: hypospadias cripples.

Make no mistake: this “crippling” isn’t caused by the hypospadias; it’s caused by the complications of surgeries to “fix” hypospadias. In the vast majority of cases, initial “repair” of hypospadias is not done because a boy’s health is being actively compromised by this anatomical quirk; his health is not. In fact, in most cases, the surgery increases the odds a boy is going to suffer from urological problems. If what you care about is improving physical health, in most cases you would not go through with “hypospadias repair.”

And consider one of the most shocking findings of the German study: “all but 6 [of the 225 men diagnosed with hypospadias] were not aware of any penile anomaly, all but 1 homosexual patient have fathered children…. [A]ll patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream.” So why label them as anything but normal?

Most hypospadias “repairs” performed by surgeons occur because of an untested, Freudian belief that you can’t grow up a “real man” if you urinate and ejaculate from somewhere other than the very tip of your penis. Urology texts of the past made it pretty plain: if you don’t “fix” hypospadias, a boy might be so messed up in his gender identity that he’ll grow up gay. Few urologists today seem to believe that sexual orientation is caused by how one pees, but many still think boys’ psychological health absolutely depends on being able to pee standing up. There’s no evidence for this. Why insurance covers it, even when there is no good evidence it is necessary or beneficial, remains a mystery.

I have heard some contemporary surgeons insist that hypospadias repair is done for a “medical” reason—to ensure a boy can eventually successfully impregnate a woman though intercourse. But there are simpler, non-surgical solutions to the problem of ejaculating somewhere other than the penis’s tip, including one reported in a late-19th-century British medical journal. In that case, a man with hypospadias was reported to have impregnated his wife by ejaculating onto a long-handled spoon and inserting it into her vagina.

Of course, we have better tools today. Through my work on this subject, a few years ago I met a man with “uncorrected” hypospadias who had opted for a high-quality turkey baster. He observed to me that, so far as he and his wife were concerned, they had the best of all possible worlds: he had no trouble with erections, orgasms, and intercourse—he was healthy—and yet he couldn’t accidentally get his wife pregnant. When they wanted to conceive, they just engaged in a private thanksgiving.

Nevertheless, parents of boys with hypospadias are often led to believe “corrective” surgery is necessary and worth the risks. Urologists don’t typically suggest that, before consenting to surgery, parents talk to the men in the Hypospadias and Epispadias Association (HEA) support group, of which Jim Lake is the incoming president.

Tiger Devore, a clinical psychologist now completing his service as HEA’s president, told me in a recent phone interview that he sees signs of pediatric urologists backing off of “hypospadias repair,” and that those changes in attitude break down along generational lines. Devore attended the International Pediatric Urology Task Force on Hypospadias in Las Vegas last September, and there he observed younger urologists being much more hesitant to push “corrective” surgery, especially in relatively minor cases, because of the risks.

Devore’s observation reminded me of a set of conversations I had with one pediatric urologist. About 15 years ago, this urological surgeon told me he wished I’d stop saying that hypospadias repair was motivated by a latent homophobia—it was a necessary surgery, he said. When I ran into him a couple of years ago, he admitted to me that my activist colleagues and I had been winning in our attempts to get his colleagues to move away from so many “repair” surgeries for hypospadias. I asked him to what he attributed the change. Without pause, he replied, “American culture has really come around on the gay thing.”

Could it be that surgeons and parents have really worried that a child left to grow up with atypical genitals will be at greater risk of gender identity and sexual orientation “problems”? Well, when I was editing a handbook for parents of these children in 2005, and I asked specialist clinicians what questions parents typically had when faced with a newborn with atypical genitals, the number one question was: Will my child be gay?

After working in this field for almost 20 years, I do not believe that most parents (or physicians) are trying to eliminate the possibility of a gay child through “corrective” surgery. I don’t see this as a eugenicist agenda. I think when parents ask Will my child be gay?, most of the time they are asking something more complicated, something genuinely compassionate: Will my child be able to know love, as I have known love?

But I do think it is the case that we still have a very tangled and too often unexamined confusion over genital variation and its meanings. We need an approach that is much calmer, more organized, and less anatomically naïve. Less surgical in its “corrective” fantasies.

So what are the options, at least for hypospadias?

A pediatric psychologist asked me something like this a couple of years ago, specifically in reference to a three-year-old boy on his service. The boy was born with hypospadias and his parents had decided early on against surgery. The mother was now feeling some anxiety because the boy, whose hypospadias made it so he had to sit to pee, was noticing how boys usually stand to pee while girls sit. The psychologist was calling to ask me if I knew of a simple prosthetic option so that this boy could try standing to pee.

Yes, I replied. And I know about the prosthetic solution because I like to camp. There’s a product called Go Girl, and it’s basically a reusable little plastic funnel. You hold it under yourself when you urinate, and the pee goes shooting out in front. Transgender men (who used to be female) sometimes also use these. I suggested the psychologist buy some of these devices, perhaps in the “camo” color, take them out of the Go Girl package, and show the kid how to use them, in case he wanted to pee standing up. A few bucks spent now and then on this handy product will buy this boy time so he can decide later, when he’s mature enough, if he wants to take on genital surgery risk. By then, too, the surgeries will hopefully be better.

An even better solution than Go Girl came from another family I ran across, a family including a boy born with a small penis and hypospadias. The first set of doctors had suggested sex changing the boy, something that used to be pretty common in such cases. (If you can’t make him into a “real man,” you make him into a girl, right?) Another set of doctors had offered “hypospadias repair.” But the parents, conservative Christians, had decided to let the boy grow up without elective, risky, invasive medical procedures.

In this case, the father took an innovative approach. Hearing about the alleged importance of a boy being able to urinate the way the men around him do, the father decided to sit to pee. Following the father’s lead, so did (and do) all the other men in the family when they are around this little boy: they all sit to pee.

Rather than getting that little boy to come to their norm, they decided to go to his.

What lesson is that little American boy learning about what makes a “real man”: compassion, acceptance, joy, and love. And sitting down to pee. What would be wrong with more men like that?

To watch videos of people born with hypospadias and other relatively uncommon variations on sex anatomy talking about their lives, visit The Interface Project.

Alice Dreger
Alice Dreger is a professor of clinical medical humanities and bioethics at Northwestern University's Feinberg School of Medicine. She has written for The New York Times, The Wall Street Journal, and The Washington Post.

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