The role of androgens in clitorophallus development and possible applications to transgender patients

Abstract

Background:The clitorophallus, or glans, is a critical structure in sexual development and plays an important role in how gender is conceptualized across the life span. This can be seen in both the evaluation and treatment of intersex individuals and the use of gender-affirming masculinizing therapies to help those born with a clitoris (small clitorophallus with separate urethra) enlarge or alter the function of that structure.Objectives: To review the role of testosterone in clitorophallus development from embryo to adulthood, including how exogenous testosterone is used to stimulate clitorophallus enlargement in masculinizing gender-affirming therapy. Materials and Methods:Relevant English-language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals and the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micropenis, penis).Results: Endogenous testosterone, and its more active metabolite dihydrotestosterone, plays an important role in the development of the genital tubercle into the clitorophallus, primarily during the prenatal and early postnatal periods and then again during puberty. Androgens contribute to not only growth but also the inclusion of a urethra on the ventral aspect. Exogenous testosterone can be used to enlarge the small clitorophallus (clitoris or micropenis) as part of both intersex and genderaffirming care (in transmasculine patients, up to 2 cm of additional growth). Where testosterone is insufficient to provide the degree of masculinization desired, surgical options including phalloplasty and metoidioplasty are available. Discussion and Conclusion:Endogenous testosterone plays an important role in clitorophallus development, and there are circumstances where exogenous testosterone may be useful for masculinization. Surgical options may also help some patients reach their personal goals. As masculinizing gender-affirming care advances, the options available for clitorophallus modifications will likely continue to expand and improve.

Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm

“…In humans, the penile and clitoral prepuces are undifferentiated in early fetal development, emerging from an ambisexual genital tubercle that is capable either of penile or clitoral development regardless of genotype (Baskin et al, 2018). Even at birth-and thereafter-the clitoral and penile prepuces may remain effectively indistinguishable in persons who have certain intersex traits or differences of sex development (Pippi Salle et al, 2007;Hodson et al, 2019;Grimstad et al, 2021). The penile prepuce has a mean reported surface area of between 30 and 50 square centimeters in adults (Werker et al, 1998;Kigozi et al, 2009) and it is the most sensitive part of the penis, both to light touch stimulation and to sensations of warmth (Sorrells et al, 2007;Bossio et al, 2016).…”

Males and females have different anatomy: is this relevant to circumcision? A reply to ‘The prosecution of Dawoodi Bohra women’ by Richard Shweder

“…2 Structures with morphology intermediate between male and female are traditionally regarded as anatomical anomalies or defects. However, some recent authors prefer not to characterise these intermediate structures as abnormal (Blackless et al, 2000;Grimstad et al, 2021). Indeed, the existence of a small number of individuals whose genital morphology is intermediate between that of males and females has led to calls for recognition of three or more biological sexes (Fausto-Sterling, 1993;Dunne and Mulder, 2018).…”

“…The term 'clitorophallus' has been applied to ambiguous external genitalia (Fausto-Sterling, 1993;Miller et al, 2018). 'Clitorophallus' has even been applied as a term to include all structures derived from the genital tubercle: penis, clitoris and intermediate structures alike (Grimstad et al, 2021). 3 This is a vast area of study and cannot be explored in detail.…”

The growing and interdisciplinary field of transgender health

“…opment from embryo to adulthood and how exogenous testosterone and surgical interventions can enlarge the clitorophallus to help TGD patients achieve their goals. 9 My commentary reviews whether 5α reductase inhibitors should be considered standard treatment options for either transfeminine and transmasculine adults. 10 I do not see much of a role for this class of medication in transfeminine patients whose testosterone levels are already at goal on estrogen and antiandrogen regimens.…”

“…Grimstad et al. review the role of androgens in clitorophallus development from embryo to adulthood and how exogenous testosterone and surgical interventions can enlarge the clitorophallus to help TGD patients achieve their goals 9 . My commentary reviews whether 5α reductase inhibitors should be considered standard treatment options for either transfeminine and transmasculine adults 10 .…”