Journal of Pediatric Psychology, Vol. 26, No. 8, 2001, pp. 465-475
© 2001 Society of Pediatric Psychology
Psychosocial Adaptation of Middle Childhood Boys With Hypospadias After Genital Surgery
1 University at Buffalo, New York, 2 Columbia University, New York, 3 Westchester Medical Center, Valhalla, New York, 4 St. Agnes Hospital, White Plains, New York
All correspondence should be sent to David E. Sandberg, Pediatric Psychiatry and Psychology, Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, New York 14222. E-mail: dsandber{at}buffalo.edu .
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Abstract |
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Objective: To compare the psychosocial adaptation of boys with hypospadias after genital surgery to a community sample.
Methods: Boys (6 to 10 years) with a history of hypospadias repair (n = 175) were compared with a community sample (n = 333) in a postal questionnaire survey using the Child Behavior Checklist.
Results: Few significant differences between cases and controls emerged. Boys with hypospadias were (slightly) lower in social involvement but did not perform more poorly in school. Boys with hypospadias displayed fewer externalizing behavior problems than controls, but a significant difference in nocturnal enuresis was not detected. Level of behavior problems did not differentiate hypospadias severity subgroups, but greater surgical and hospitalization experiences were associated with increased internalizing problems. Poorer cosmetic appearance of the genitals was associated with worse school performance.
Conclusions: Surgically corrected hypospadias should not be considered a risk factor for poor psychosocial adaptation in childhood, but emotional problems increase with the number of hospital-related experiences.
Key words: hypospadias; psychological adaptation; childhood behavior; hospitalization; surgery.
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Introduction |
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This study concerns the psychosocial adaptation of boys born with hypospadias, a congenital anomaly of the penis. Hypospadias is the consequence of incomplete development of the anterior urethra that results in the urethral meatus terminating at various levels on the undersurface of the penis (Levitt & Reda, 1988
). The
position of the urethral opening classifies the defect: glandular and coronal
hypospadias denote a meatus situated on the glans penis or on the coronal
sulcus; penile, penoscrotal, and perineal hypospadias refer to conditions in
which the urethra terminates along the shaft of the penis, at the penoscrotal
junction, or on the perineum, respectively. Hypospadias is a relatively common
urogenital anomaly with a reported incidence of approximately 40 per 10,000
(Paulozzi, Erickson, & Jackson,
1997). Corrective surgery, in which reconstruction of the distal
urethra is performed, is frequently necessary to ensure normal voiding in the
standing position. Improved cosmetic appearance of the genitalia has also
become recognized as an objective of surgical correction
(Zaontz & Packer,
1997).
In recent years, consumer activists and social scientists have called for a
reduction in the frequency of genital surgery because of the potential of
surgical complications, unsatisfactory anatomic and functional outcome, and
related emotional trauma (Dreger,
1998; Fausto-Sterling,
2000; Intersex Society of North America,
1994,
1995;
Kessler, 1998). Although the
surgical management of individuals born with ambiguous genitalia has garnered
most of the attention in this wide-ranging debate, parents and surgeons are
also admonished to avoid hypospadias repair for cosmetic reasons
(Fichtner, Filipas, Mottrie, Voges, &
Hohenfellner, 1995; Intersex
Society of North America, 1994). Unfortunately, there is little
systematic documentation of the medium- or long-term outcomes of genital
surgery to support such a change in clinical practice.
Several factors might contribute to an increased risk of poorer
psychosocial adaptation in boys with hypospadias showing. This group will
generally experience the stressors of hospitalization and genital surgery,
frequently on multiple occasions. Although it has been demonstrated that the
experience of (brief) hospitalization does not, of itself, place children at
greater risk for the future development of psychopathology
(Thomson & Vernon, 1993),
reports continue to suggest that subgroups of children may experience adverse
reactions to hospitalization and surgery (e.g.,
Lumley, Melamed, & Abeles,
1993). One retrospective investigation indicates that
genitourinary surgery, specifically, may be associated with poorer
postsurgical psychological adjustment
(Blotcky & Grossman, 1978).
In that study, girls and boys 7 to 17 years old with the experience of
genitourinary surgery showed increased emotional disturbance. A similar
association was not detected for children who had undergone ear, nose, and
throat surgery, such as tonsillectomy or myringotomy.
The development of social competencies (e.g., peer relations, participation
in organized peer groups) might suffer among boys with hypospadias since they
are at an increased risk of developing a distorted body- and self-image
secondary to the anomalous appearance and abnormal functioning (e.g., urine
spraying) of the genitals (Money, Devore,
& Norman, 1986; Money,
Lehne, & Pierre-Jerome, 1985).
Factors potentially interfering with academic achievement in boys with hypospadias include, in extreme cases, repeated doctor visits and hospitalizations, which may disrupt regular school attendance. The school environment may become an aversive social setting for some of these boys because the deviant appearance and impaired function of their genitals may contribute to the child becoming the target of teasing by peers and developing a diminished self-image.
Few studies have investigated the psychosocial adjustment of individuals
with this condition and only two have incorporated control subjects. One
Swedish study evaluated the psychosocial adaptation of 34 hospital
chart-selected men ages 21 to 34 years (M = 27.2 years), who were
born with hypospadias of varying degrees
(Berg, Berg, & Svensson,
1982; Berg, Svensson, &
ström,
1981). This group was compared to that of a demographically
matched sample of 36 men who had been operated on for verified appendicitis at
the same age as the pair-matched probands' urethral reconstruction. The men
born with hypospadias more frequently recalled depression and anxiety in
addition to poorer adjustment with peers during childhood. Because information
pertaining to the childhood development of this group was based upon adult
recall of childhood events, these data might be distorted by adult
experiences.
In a more recent investigation in the Netherlands
(Mureau, Slijper, Slob, & Verhulst,
1997), the psychosocial functioning of 116 children and
adolescents 9 to 18 years old (M = 14.4 years) was compared with 88
age-matched control participants who had received treatment (not including
genital surgery) for an inguinal hernia. All hypospadias cases had received
corrective surgery. The hypospadias group did not exhibit an excess of
behavior problems, either by parent- or self-report. Items on these
questionnaires concerned specifically with "sex problems" also did
not differentiate the groups, nor did two parent-report items concerned with
enuresis. Further, relationships between patient medical characteristics
(i.e., degree of hypospadias, number and type of surgical procedures, and age
at which surgery was completed) and criteria variables of psychosocial
adaptation were not statistically significant. However, those patients with a
more negative perception of their genital appearance exhibited a poorer
psychosocial adjustment.
In our own previous investigation of boys with surgically corrected
hypospadias (Sandberg, Meyer-Bahlburg,
Aranoff, Sconzo, & Hensle, 1989), we compared 69 medical chart
selected boys ages 6 to 10 years (M = 7.6 years) with either mild
(coronal or penile) or severe hypospadias (penoscrotal or perineal and all
cases of hypospadias associated with a hypoplastic penis) to the
standardization norms of the same parent-report checklist of social
competencies and behavior problems as the one used (in Dutch translation) by
Mureau et al. (1997). To
minimize recruitment bias, we selected cases independent of any information
regarding the child's psychosocial adaptation. Boys with hypospadias showed
significantly lower social competency and more behavior problems than norms
based on a nonclinical sample of boys. They were better adjusted, however,
than a psychiatric-clinical comparison group. In contrast to Mureau et al.
(1997), we found that scores
on two items ("wets self during the day" and "wets the
bed") revealed an excess of such problems comparable to levels observed
in a psychiatric-referred norm sample. Finally, surgery-related
hospitalizations were marginally correlated with poorer school
performance.
A research design weakness of the Sandberg et al.
(1989) study was that it did
not incorporate a study-recruited control group, using instead published norms
for nonclinical and clinical samples, a procedure fraught with interpretative
hazards (Sandberg, Meyer-Bahlburg, &
Yager, 1991). This study, an extension of our earlier work,
assesses the psychosocial adaptation of a much larger sample of boys with
hypospadias of varying degrees. A locally recruited nonclinical control group
is incorporated into the design, and statistical analyses take into
consideration socioeconomic and demographic differences between the
groups.
The ongoing controversy about the psychological effects of genital surgery prompted us to analyze the pertinent variables within an existing data bank of ours on the largest hypospadias sample studied to date with psychological methods. We address the following questions. In comparison to community controls, do boys with hypospadias show (1) deficiencies in social competencies, (2) poorer academic achievement, or (3) more behavior problems? Within the hypospadias sample, do boys whose hypospadias is associated with additional significant physical and/or intellectual disabilities show predictable behavioral deficits? Is the severity of the hypospadias, the experience of repeated surgeries, or parental perceptions of the appearance of the genitals related to social competency, school performance, or behavior problems?
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Method |
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Participants
Hypospadias Group. Participants were selected from the files of pediatric urologists from two programs at major New York City medical centers. The patients were treated at three hospitals and were recruited between 1985 and 1987. Included are data from participants recruited at one center (n = 69) that have previously been reported (Sandberg et al., 1989
). All
boys, 6 to 10 years of age, who were born with hypospadias with or without
additional genital or nongenital malformations were targeted. An exclusion
criterion was the absence in the home of at least one English-speaking parent
to complete the questionnaires. A total of 251 boys met both of the inclusion
criteria. Thirty-four families could not be located even after extensive
tracing. Of the 217 households contacted by mail, the parents/guardians of 204
boys (94%) participated; of the remainder, 13 families (5%) refused or did not
return the questionnaires. Because the study was limited to boys 6 to 10 years
old, 18 participants were excluded from analysis because they had turned 11
years old by the time the questionnaires were completed. Because an
association of the genital defect with marked other physical and/or
intellectual impairments might confound the interpretation of the findings, we
also excluded a further 11 boys experiencing additional serious disabilities
(based on information from both medical charts and parental report) from the
primary analyses (Table I). A
sample of 175 boys with hypospadias remained for statistical analysis. These
were partitioned according to the severity of the genital defect: the first
subgroup (n = 136) included boys born with either glandular
(n = 81) or penile (n = 55) hypospadias but with a
normal-sized penis. The second subgroup (n = 36) included cases of
either penoscrotal or perineal (n = 29) hypospadias (but with a
full-sized penis), and all cases (n = 7) of hypospadias associated
with a hypoplastic penis. In three cases, the medical record was not clear
enough to confidently establish the severity of the hypospadias, and they were
excluded from the severity analysis. All participants had received some
genital corrective surgery by the time of the survey. Demographic
characteristics for the total hypospadias sample (N = 175) are
summarized in Table II. The
sample was predominantly white, and the parents' combined mean educational
background was approximately equal to completion of a college degree.
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Comparison Group. All children 6 to 10 years of age who attended elementary schools comprising a complete school district of one northern New Jersey city were eligible to serve as control participants. Data were collected over 2 academic years (1986 to 1988). The absence of an English-speaking parent/guardian was the sole exclusion criterion; 479 boys were eligible. The parents of 99 children (21%) refused to participate. Parents of an additional 24 (5%) either could not be contacted by repeated phone calls or home visits, or the child left the school district after the survey had begun but before the parent had an opportunity to participate, or the child's guardian had insufficient information on the child to participate in the survey. The parents of 356 boys (74% of the eligible sample) agreed to participate, but data are analyzed here only for the 333 boys who were 6 to 10 years old at the time the completed questionnaires were received. Demographic characteristics for the community sample are summarized in Table II.
Procedures
Hypospadias Group. Parents were contacted by mail through treating
physicians' offices and were asked to participate in a survey designed to
determine "to what extent various medical conditions and their treatment
affect the child as well as his family." A $5 honorarium was offered.
Ambiguous responses were clarified and missing items completed by phone, if
necessary.
Comparison Group. A letter from the school principal, originating from the school and accompanied by a more detailed letter from our research unit, was sent to the parents. The study was described as an investigation of general behavioral development and problem behaviors among children with varied medical backgrounds. Parents were ensured that survey information was confidential and would be made available to the schools only in the aggregate.
Consent. Parents provided written informed consent for the study by mail prior to the questionnaire packet being sent to the home. The research protocol was approved by the institutional review boards (IRB) of the Department of Psychiatry of Columbia University and the Westchester Medical Center (WMC). These approvals covered the study at all three sites because participants from the third hospital were all under the personal care of urologists from the WMC and were contacted from their WMC office. The participating New Jersey school district accepted the IRB review of Columbia University in lieu of conducting their own.
Instruments. A parent, most often the mother (90%), served as the informant.
- Social Competencies and Psychiatric Symptoms. The Child Behavior Checklist
(CBCL; Achenbach & Edelbrock,
1983) includes 20 items assessing social competencies falling into
three content domains (Activities, Social, and School). Behavioral/emotional
adaptation is assessed by 118 behavior problem items factor analyzed into
several narrow-band factors (nine in the case of boys 6 to 11 years) and two
second-order factors (internalizing and externalizing) reflecting the
distinction between fearful, inhibited, and overcontrolled behavior versus
aggressive, antisocial, and undercontrolled behavior. Indices of reliability
and validity for the CBCL demonstrate acceptable psychometric properties
(Achenbach & Edelbrock,
1983). (All the data for this study were collected between 1985
and 1988, prior to the revision of the CBCL factor structure and renorming of
the checklist [Achenbach,
1991]. The major advantage in the 1991 factor structure is that it
permits comparisons across genders and age groups, a feature irrelevant to
these analyses because comparisons between the hypospadias and community
sample are within gender and for a narrow age range. Further, this study does
not use either the 1983 or 1991 CBCL norms for comparisons with the
hypospadias group.) Because of inconsistencies in findings regarding enuresis
in hypospadias samples (Berg et al.,
1982; Mureau et al.,
1997), we examined individual CBCL items dealing with this
condition ("wets self during the day" and "wets the
bed"). Following Mureau et al.,
(1997) we also conducted an
item analysis of four CBCL "sexual problem" items ("plays
with own sex parts in public," "plays with own sex parts too
much," "sexual problems," and "thinks about sex too
much").
- Academic Achievement. This domain was assessed by the CBCL School scale,
which summarizes items related to school performance (e.g., performance in
academic subjects, and whether the child attends a special class because of
learning problems or has repeated a grade).
- Genital Surgery, Total Hospitalizations, Hypospadias Severity, and Genital
Appearance. Information regarding the number of separate occasions on which
the child received genital surgery was excerpted from the hospital chart, as
were descriptions of the severity of the hypospadias at birth. Information on
the boys from two of the three urology programs (n = 106) pertaining
to the total lifetime number of hospitalizations (including those unrelated to
the hypospadias repair) and parent perceptions of the child's genital status
(appearance and function) subsequent to hypospadias repair were collected by
telephone interview after completion of the postal survey. Genital appearance
was rated by a parent on a 10-point scale (1 = completely normal appearance,
10 = extremely abnormal appearance) and micturition position on a 5-point
scale (1 = always urinates sitting down, 5 = almost always urinates
standing).
- Additional Survey Methods. Findings related to gender development and the
impact of the child's diagnosis and treatment on family coping with
hypospadias are described elsewhere
(Sandberg et al., 1989;
Sandberg et al., 1995).
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Results |
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Two approaches were chosen in analyzing the data. First, the psychosocial and educational adaptation of the boys with hypospadias was compared with the school comparison group, taking into consideration demographic differences between the two. Hierarchical multiple regression and logistic regression analyses were employed at this stage. Hierarchical multiple regression was also used in the next stage, which assessed the influence of factors such as medical experiences and characteristics of the genital defect on boys' psychosocial adaptation. Because of the relatively large sample sizes for both groups, there was sufficient statistical power to detect even small differences.
Hypospadias and Social Competencies
Although the unadjusted mean scale scores were the same for both the
hypospadias and control groups, a hierarchical multiple regression analysis
that statistically controlled for participant's age, race/ethnicity, and
combined parental education, showed significantly lower scores on the social
competency scale for the hypospadias boys (r2 change
=.008, F change = 4.05, p =.04;
Table III). This scale includes
items assessing membership and participation in organizations; number and
frequency of contacts with friends; quality of relationship with siblings,
friends, and parents; and the child's solo independence skills (how well the
child plays and works by himself). The effect of participant clinical status
on the Social scale reflects a small, general shift downward in the scores of
the hypospadias participants. Statistically significant differences were not
detected on either the Activities or Total Social Competency scale scores.
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Hypospadias and Academic Achievement
A significant difference was not detected between the hypospadias and
control group on the School scale of the CBCL, F change = 0.39,
p =.53.
Hypospadias and Behavior Symptoms
Participants with hypospadias received significantly lower behavior problem
scores (i.e., showed less behavior disturbance) than the school sample on the
CBCL Aggressive (r2 change =.010, F change =
5.00, p =.03), and Delinquent scales (r2 change
=.016, F change = 8.72, p =.003). Both scales load on the
second-order externalizing factor, and the latter also shows significantly
lower scores for the hypospadias boys (r2 change =.010,
F change = 5.42, p =.02;
Table III; a complete table of
scale scores is available from Dr. Sandberg). There were no differences
between the groups on any of the other behavior problem scales.
In logistic regression, in which participant's age, race/ethnicity, and
parents' combined education were controlled, comparable percentages of the
hypospadias (4.0%) and school (1.8%) samples exhibited diurnal enuresis
("wets self during the day") either "somewhat or sometimes
true" (rating of 1) or "very true or often true" (2)
(improvement 
2 [1] = 2.17, p =.14). The difference in
parent reports of nocturnal enuresis ("wets the bed") (20.1% for
boys with hypospadias vs. 13.0% for the control boys) also did not achieve
statistical significance (improvement 2 [1] = 2.83, p
=.09). Ratings for the items "plays with own sex parts in public"
(4.0% and 4.2% for the hypospadias and school samples, respectively;
improvement 2 [1] =.003, p =.96) and "plays
with own sex parts too much" (6.3% and 3.0%; improvement
2 [1] = 1.47, p =.22) did not differentiate the
groups. In contrast, a significantly higher percentage of the hypospadias
(2.3%) than school (0.0%) participants received a positive rating (either a 1
or 2) on the item "sexual problems," (improvement
2 [1] = 5.70, p =.02). The reverse was true for the
item "thinks about sex too much," on which a higher percentage of
the school (7.6%) than hypospadias participants (1.7%) were rated positive
(improvement 2 [1] = 5.21, p =.02).
Hypospadias, Additional Disabilities, and Psychosocial
Adjustment
As expected, the 11 boys who had additional marked physical and/or
intellectual disabilities (Table
I) were rated as significantly more poorly adjusted on the
majority of scales than the school sample
(Table IV).
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Number of Genital Surgeries, Total Number of Hospitalizations,
Hypospadias Severity, Genital Appearance/Function, and Psychosocial
Functioning
The total number of separate corrective surgical procedures ranged from 1
to 13 (M = 2.5, SD = 1.8, median = 2.0). Partial
correlations adjusting for participants' age, race/ethnicity, and parents'
educational attainment showed that a greater number of surgeries were
associated with an increase in scores on the CBCL Depressed scale
(r2 change =.029, F change = 4.76, p
=.03). Essentially the same result was detected when the total number of
overnight hospitalizations (not adjusting for number of surgeries, which was
correlated with hospitalizations, 0.68, p <.001) was used as the
predictor variable. Both the Depressed (r2 change =.065,
F change = 6.49, p =.01) and Social Withdrawal
(r2 change =.046, F change = 4.43, p
=.04) scale scores increased significantly with the total number of
hospitalizations.
Boys with more severe genital defects received a greater number of surgical repairs (M = 4.2, SD = 2.3) than those born with less severe anomalies (M = 2.1, SD = 1.4). Hierarchical multiple regression analyses controlling for participant's age, race, and parents' educational attainment as well as the number of genital surgeries did not reveal statistically significant differences between the groups on CBCL scale scores. The results remain essentially unchanged if the analyses are repeated without statistically correcting for the number of genital surgeries.
The mean rating for parent-perceived genital appearance (1 = completely normal, 10 = extremely abnormal) was 2.7 (SD = 1.7, range = 1 to 9). Partial correlations between genital appearance (controlling for subject's age, race/ethnicity, and parents' education) and CBCL scale scores did not reveal statistically significant associations. The degree of abnormal genital appearance was significantly correlated with hypospadias severity (r = 0.23, p =.03) and total number of hospitalizations (r = 0.22, p =.04) (but not with the total number of genital surgeries, r = 0.13, p =.21). However, when statistically adjusting for both medical experiences (in a partial correlation), more abnormal genital appearance was found to be associated with a significantly poorer CBCL school competency score (r = -0.22, p =.046).
All but 3 of 97 patients (97%) for whom data were available received a rating of "almost always standing" to urinate. There was thus too little variability on this measure to formally examine the relationship with the psychosocial variables. Inspection of scale scores for the subgroups, however, showed that the three boys who urinated sitting received substantially higher total behavior problem scores (36.0) than the others (24.1). The excess problems were particularly of an externalizing type (20.3 vs. 10.8). Total social competency scores were virtually identical in these two subgroups (19.5 and 19.2). In contrast, this subgroup was no more likely than the remainder of the sample to have experienced a greater number of surgeries or of hospitalizations or to be exhibiting symptoms of enuresis or increased gender-atypical behavior.
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Discussion |
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This study comparing the psychosocial adaptation of middle childhood boys who had undergone hypospadias repair with a school sample detected few differences. Boys with hypospadias showed slightly less social involvement but did not perform more poorly in school. Participants with hypospadias exhibited fewer externalizing behavior problems than the community sample. The prevalence of enuresis did not differentiate the groups. The percentage of unique variance in scale scores attributable to clinical status (hypospadias vs. control) ranged between 1% and 2%. All other findings related to variability within the hypospadias sample should be judged within this context. The level of behavior problems was not different between hypospadias severity sub-groups, but greater surgical or hospitalization experiences were associated with increased internalizing problems. Finally, poorer cosmetic appearance of the genitals after hypospadias repair was associated with worse school performance.
These findings of adaptive psychosocial functioning among postsurgical boys
with hypospadias are consistent with those of Mureau et al.
(1997), who studied older
children, adolescents, and adults in the Netherlands. Both investigations
provide a more positive picture than the Berg et al. study
(1981,
1982) in Sweden, which used a
much smaller sample and relied upon recall of childhood events that might be
distorted by adult experiences. In contrast with our earlier work
(Sandberg et al., 1989), which
suggested a heightened risk of behavior problems among these children in
comparison to published norms, this study underscores the importance of
employing appropriate control-group comparison procedures.
An interesting and unexpected finding was that the hypospadias group in this study was described by parents as showing significantly fewer conduct problems than the comparison group. Closer parental supervision of the child stemming from concern related to the child's genital anomaly and associated treatment may have been a factor. An element of parental overprotection may also have been a factor in the lower scores on the social competency scale.
The optimistic picture for the patient group studied here is qualified when considering the adaptation of those boys whose hypospadias was only one feature of otherwise severe and chronic medical histories (Table I). These boys were found to be functioning substantially more poorly than the control group. This observation suggests that follow-up studies of hypospadias and related urological patient groups need to take into account not only the specific condition that is the focus of the study but also additional severe somatic or mental abnormalities likely to interfere with the attainment of a psychosocial outcome comparable to that of controls.
In contrast to our earlier report, the hypospadias group in this study was
not found to exhibit nocturnal enuresis significantly more frequently than the
control group. However, because of the emotional distress that can be
associated with enuresis (Walker,
1995), it may be prudent to treat this behavior if it is chronic
and occurs with some frequency after the age of 5 years
(American Psychiatric Association,
1994). Behavioral or pharmacologic interventions should be
considered, however, only after potential genital anatomic contributors to the
problem have been ruled out (Mellon &
McGrath, 2000).
The proportion of hypospadias participants who were reported on the CBCL to
be exhibiting "sexual problems" was significantly higher than in
the school sample. In the case of the Mureau et al.
(1997) report, the difference
between cases and controls was even more marked, yet the differences did not
achieve statistical significance. Exploration of parents' reasons for rating
this problem as present in this small subgroup of participants is
warranted.
The relatively high socioeconomic status of our sample potentially acted as
a moderating influence (Holmbeck,
1997) contributing to positive outcomes. Close to 60% of parents
seeking surgery for their sons from the urologists in this study had completed
either a 4-year college or graduate degree. We have already reported that
these families are coping well with the stresses related to their sons'
hypospadias and its correction (Sandberg et al., 1987). Samples of boys with
hypospadias from lower socioeconomic strata, and whose lives are otherwise
challenged by multiple social-environmental stresses, might not fare as well
(Wallender & Varni,
1992).
The cosmetic appearance of the postsurgical penis and its function may have
served as an additional moderating variable. In this study, the majority of
parents perceived their son's penis as quite normal in appearance and their
ability to urinate in a standing position as uncompromised. Nevertheless, a
more negative appraisal by a parent of the child's genital appearance was
associated with greater school problems. We also observed that behavioral
adaptation was poorer in those very few boys in whom genital function was
compromised, as evidenced by the boys needing to urinate while sitting. Thus,
behavioral/emotional adaptation might be poorer in subgroups of patients for
whom post-surgical genital appearance and/or function are more severely
affected. The importance of a positive appraisal of genital appearance also
emerges in the research of Mureau and colleagues
(1995). They showed that
patients ages 9 to 12 years old who had received surgical repair of their
hypospadias anticipated that they would be inhibited in sexual relations
because of penile appearance. The proportion of patients expressing such
anxiety was significantly higher than the proportion in the comparison group.
It may be that psychosocial functioning of boys with hypospadias does not
fully predict sociosexual functioning in adolescence and adulthood, and that
the latter explains the poorer outcome data for the adult sample of Berg et
al. (1981,
1982). Thus, cosmetic
appearance of the penis and its relationship to psychosocial and psychosexual
outcomes in adulthood warrant further study.
The following limitations of the study should be noted. First, details of
the child's psychosocial adaptation were obtained from a single informant, a
parent (typically the mother). It would be important to corroborate these
findings by extending the sources of information to include the boys
themselves, fathers, teachers, and even peers. Second, the postal survey
format restricts the degree of control the investigator has over the process
of data collection. Third, only the clinical sample was offered a nominal
honorarium (to facilitate participation). Given that many families declined
payment, there is no reason to believe that this difference in recruitment
procedures influenced parental reports. Fourth, because the CBCL is a generic
psychosocial screening tool, further studies ideally would incorporate methods
that may be more sensitive to the specific challenges that youths with genital
defects are likely to encounter. Finally, the data reported in this study were
collected between 12 to 15 years ago. There is no reason to assume, however,
that children's reactions to genital surgery would be any worse today than at
that time, considering the continuing improvements in genital surgical
techniques (Borer & Retik,
1999) and the accommodations made in pediatric care settings to
minimize the deleterious effects of hospitalization and associated medical
procedures (Harbeck-Weber & Hepps
McKee, 1995).
It has been suggested that hypospadias repair engenders "emotional
trauma" and that "surgery is frequently very harmful, both
physically and surgically" (Intersex
Society of North America, 1994). Although this study does not
directly address the immediate or short-term emotional consequences of genital
surgery, the findings do not suggest that hypospadias repair is associated
with lasting emotional or behavioral consequences in childhood. However, given
that emotional problems may increase with the number of hospital/surgical
experiences, this factor should be carefully considered in the clinical
management of hypospadias. Although these findings are reassuring, they do not
guarantee that these individuals will be free of special challenges to their
future psychosexual development.
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Acknowledgments |
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David E. Sandberg has been supported by National Research Service Award HD06726 from the NICHD. In addition, this work was supported in part by Biomedical Research Support Grant S07RR05650-17, grant 84-0982-84 from the William T. Grant Foundation, NIMH Research Grant R03 MH-40914, and NIMH Clinical Research Center Grant MH-30906. We thank the parents who participated in the study. We also thank Joan Romo and Debbie Kornfeld for their help in data collection and analyses of results from the survey.
Received May 4, 2000; revision received October 31, 2000; revision received December 27, 2000; accepted January 9, 2001
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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