madman
Super Moderator
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 lifespan. 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 as well as 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, play 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 gender-affirming care (in transmasculine patients, up to 2cm 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.
Introduction
At the time of birth, one anatomic structure has historically been central to the immediate postnatal determination of sex (and for many decades, gender). The size of this structure on prenatal ultrasounds may lead parents to hypothesize elements of their future child’s life course as well as decision-making around everything from names to room color.1,2 Alteration of this structure is central to religious identity for some individuals and deeply offensive to others.3–5 This structure is the clitorophallus (Table 1).
The clitorophallus is most often referred to as either a penis or clitoris. This reflects the two most common developmental pathways, typically referred to as male and female. Clitorophallus size, the presence of other genital structures (e.g., vagina, scrotum), and the location of the urethra often dictate whether the clitorophallus is referred to as a penis (enlarged, with urethra present to tip) or a clitoris (small, urethra separate). However, requiring the clitorophallus to be categorized as either a penis or clitoris masks the range of variation seen in normal human development. Some persons have a larger clitorophallus with a discretely separate urethra or have a proximal and/or ventral urethra (e.g., hypospadias).
When there is a variation in the size or structure of the clitorophallus that makes categorization difficult, it is often referred to as an intersex trait or difference in sexual differentiation. Many such variations are non-pathologic and do not require acute intervention, and defaulting to a binary language of clitoris or phallus limits the understanding of the diversity of this structure’s anatomic size and function.6 For example, a baby born with a prominent clitorophallus that has a urethral opening at the base might be documented as having a “micropenis with hypospadias” or an “enlarged clitoris.” Both are linguistically and clinically correct, and yet each has specific gendered outcomes attached. If the infant is labeled as having an enlarged clitoris, they will likely be said to be presumptively female sex, unless proven otherwise, and both clinical care and parental education will be provided with that foundation. Alternatively, if an infant is labeled as having a micropenis with hypospadias, they will likely be presumed to be male, and clinical counseling will prioritize viewing this structure as a penis in need of modifications.
Defaulting to language that forces a spectrum of clitorophallus development into binary options limits the ability of parents, patients, and providers to understand the functionality and diversity of this androgen-sensitive structure, particularly in the context of anatomical (intersex) and gender diversity. There is growing evidence that using the size and structure of the clitorophallus to assign gender and sex can be problematic, as sex and gender are not the same in all persons and sex is not a binary state.7–9 Some people with a small clitorophallus may desire a larger one and vice versa, but sex is not the only predictor of that goal. Individual assessment of and goals for the clitorophallus also reflect gender identity, functional desires, perceptions of normality, medicalization, and cultural influence.6,10 To explicitly recognize the developmental diversity of the postnatal structure which develops from the genital tubercle in utero, this study will utilize the term clitorophallus, unless specifically referencing another study’s data (In practice, clinicians and researchers should routinely ask individuals to share their preferred terms for any relevant aspects of their anatomy and use those terms throughout the visit.).
Despite the clitorophallus’ central role in many of life’s milestones and intimate relationships, it is typically an aside or afterthought in discussions of the effects of androgens on the body. Most literature on the clitorophallus surrounds early medical and surgical interventions used to address structural variations, including hypospadias and micropenis. Other research takes places in the context of gender-affirming care, where those who are born with a small clitorophallus and separate urethra may desire to enlarge this structure as a part of masculinization therapies.11
As our understanding as clinicians improves regarding the nature of sex and gender diversity it is time to revisit the clitorophallus and understand its origins, development, and modifications and the central role androgens play at each stage thereof. This paper will 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. To do this, relevant English language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals as well as the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micro-penis, penis).
*Prenatal Development of the Clitorophallus
*Prenatal Clitorophallus Development under Full Androgen Exposure
*Prenatal Clitorophallus Development under No Androgen Exposure
*Prenatal Clitorophallus Development under Partial Androgen Exposure
*Prenatal Urethral Plate Development
*The Clitorophallus at the Time of Birth
*The Clitorophallus at the Time of Puberty
*Using Exogenous Androgens to Modify the Clitorophallus
-Clitorophallus Modifications in Patients with Intersex Traits or Differences in Sexual ----Development
-Clitorophallus Modifications in Gender Affirming Care
*Clitorophallus Enlargement and Modification Surgeries
-Counseling and Preoperative Considerations
-Metoidioplasty
-Phalloplasty
*Sexual Function of the Clitorophallus
Conclusion
The clitorophallus can be an important part of an individual’s anatomy. It has the highest concentration of nerve endings in the human body, has the ability to become erect, and can contribute to pleasure and orgasm. Much of the development of the clitorophallus is driven by the presence of and response to androgens. Prenatally, this leads to a range of development from the small clitorophallus with the external urethra, commonly referred to as the clitoris, to the larger clitorophallus with a ventral urethra, commonly referred to as the penis.
There is mixed evidence about the use of exogenous testosterone to affect the size and function of the clitorophallus. Where people desire changes to their clitorophallus to affirm their gender identity, there are several options. Androgens can be used to enlarge the clitorophallus.
Surgical modifications can be used to change both its size and function, including releasing the fascia, moving the clitorophallus to an anatomic location in line with a penile location, elongating the urethra along the dorsum, and creating a full neophallus. There are less data about the success of using exogenous testosterone on individuals with functional testes, including those with various intersex traits.
Further research is needed to understand the psychological and physical (including urinary and sexual) outcomes of various clitorophallus modifications as well as the reasons people do and do not choose various options. Additional research is also needed to understand which if any postpubertal hormonal therapies are superior in achieving clitorophallus enlargement in transmasculine individuals with minimal prior androgen exposure.
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 as well as 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, play 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 gender-affirming care (in transmasculine patients, up to 2cm 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.
Introduction
At the time of birth, one anatomic structure has historically been central to the immediate postnatal determination of sex (and for many decades, gender). The size of this structure on prenatal ultrasounds may lead parents to hypothesize elements of their future child’s life course as well as decision-making around everything from names to room color.1,2 Alteration of this structure is central to religious identity for some individuals and deeply offensive to others.3–5 This structure is the clitorophallus (Table 1).
The clitorophallus is most often referred to as either a penis or clitoris. This reflects the two most common developmental pathways, typically referred to as male and female. Clitorophallus size, the presence of other genital structures (e.g., vagina, scrotum), and the location of the urethra often dictate whether the clitorophallus is referred to as a penis (enlarged, with urethra present to tip) or a clitoris (small, urethra separate). However, requiring the clitorophallus to be categorized as either a penis or clitoris masks the range of variation seen in normal human development. Some persons have a larger clitorophallus with a discretely separate urethra or have a proximal and/or ventral urethra (e.g., hypospadias).
When there is a variation in the size or structure of the clitorophallus that makes categorization difficult, it is often referred to as an intersex trait or difference in sexual differentiation. Many such variations are non-pathologic and do not require acute intervention, and defaulting to a binary language of clitoris or phallus limits the understanding of the diversity of this structure’s anatomic size and function.6 For example, a baby born with a prominent clitorophallus that has a urethral opening at the base might be documented as having a “micropenis with hypospadias” or an “enlarged clitoris.” Both are linguistically and clinically correct, and yet each has specific gendered outcomes attached. If the infant is labeled as having an enlarged clitoris, they will likely be said to be presumptively female sex, unless proven otherwise, and both clinical care and parental education will be provided with that foundation. Alternatively, if an infant is labeled as having a micropenis with hypospadias, they will likely be presumed to be male, and clinical counseling will prioritize viewing this structure as a penis in need of modifications.
Defaulting to language that forces a spectrum of clitorophallus development into binary options limits the ability of parents, patients, and providers to understand the functionality and diversity of this androgen-sensitive structure, particularly in the context of anatomical (intersex) and gender diversity. There is growing evidence that using the size and structure of the clitorophallus to assign gender and sex can be problematic, as sex and gender are not the same in all persons and sex is not a binary state.7–9 Some people with a small clitorophallus may desire a larger one and vice versa, but sex is not the only predictor of that goal. Individual assessment of and goals for the clitorophallus also reflect gender identity, functional desires, perceptions of normality, medicalization, and cultural influence.6,10 To explicitly recognize the developmental diversity of the postnatal structure which develops from the genital tubercle in utero, this study will utilize the term clitorophallus, unless specifically referencing another study’s data (In practice, clinicians and researchers should routinely ask individuals to share their preferred terms for any relevant aspects of their anatomy and use those terms throughout the visit.).
Despite the clitorophallus’ central role in many of life’s milestones and intimate relationships, it is typically an aside or afterthought in discussions of the effects of androgens on the body. Most literature on the clitorophallus surrounds early medical and surgical interventions used to address structural variations, including hypospadias and micropenis. Other research takes places in the context of gender-affirming care, where those who are born with a small clitorophallus and separate urethra may desire to enlarge this structure as a part of masculinization therapies.11
As our understanding as clinicians improves regarding the nature of sex and gender diversity it is time to revisit the clitorophallus and understand its origins, development, and modifications and the central role androgens play at each stage thereof. This paper will 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. To do this, relevant English language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals as well as the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micro-penis, penis).
*Prenatal Development of the Clitorophallus
*Prenatal Clitorophallus Development under Full Androgen Exposure
*Prenatal Clitorophallus Development under No Androgen Exposure
*Prenatal Clitorophallus Development under Partial Androgen Exposure
*Prenatal Urethral Plate Development
*The Clitorophallus at the Time of Birth
*The Clitorophallus at the Time of Puberty
*Using Exogenous Androgens to Modify the Clitorophallus
-Clitorophallus Modifications in Patients with Intersex Traits or Differences in Sexual ----Development
-Clitorophallus Modifications in Gender Affirming Care
*Clitorophallus Enlargement and Modification Surgeries
-Counseling and Preoperative Considerations
-Metoidioplasty
-Phalloplasty
*Sexual Function of the Clitorophallus
Conclusion
The clitorophallus can be an important part of an individual’s anatomy. It has the highest concentration of nerve endings in the human body, has the ability to become erect, and can contribute to pleasure and orgasm. Much of the development of the clitorophallus is driven by the presence of and response to androgens. Prenatally, this leads to a range of development from the small clitorophallus with the external urethra, commonly referred to as the clitoris, to the larger clitorophallus with a ventral urethra, commonly referred to as the penis.
There is mixed evidence about the use of exogenous testosterone to affect the size and function of the clitorophallus. Where people desire changes to their clitorophallus to affirm their gender identity, there are several options. Androgens can be used to enlarge the clitorophallus.
Surgical modifications can be used to change both its size and function, including releasing the fascia, moving the clitorophallus to an anatomic location in line with a penile location, elongating the urethra along the dorsum, and creating a full neophallus. There are less data about the success of using exogenous testosterone on individuals with functional testes, including those with various intersex traits.
Further research is needed to understand the psychological and physical (including urinary and sexual) outcomes of various clitorophallus modifications as well as the reasons people do and do not choose various options. Additional research is also needed to understand which if any postpubertal hormonal therapies are superior in achieving clitorophallus enlargement in transmasculine individuals with minimal prior androgen exposure.
