A Surgeon’s Case in the History of Intersex Medicine in Colombia

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One day, while scrolling through social media, I came across the story of Santiago, a Colombian intersex man who underwent sex reassignment surgery during his adolescence. He was born with genitals that didn’t match either feminine or masculine characteristics, and the medical staff decided to list him as female. As a teen, he was uncomfortable with his gender but was convinced by doctors that undergoing genital reconstruction and hormone treatment to become a woman was his only option. This led to depression, anxiety, and years of side effects. The story ended with him, as an adult, learning that he didn’t medically need to undergo reassignment surgery or transition to a woman, which led him to accept his male identity.

As a Colombian physician, I found his claims deeply moving. I had encountered many stories about people whose sex characteristics did not fit typical definitions of male or female bodies and who underwent surgery. Yet each time, they brought me back to the day I first learned about medical management of intersex variations and to the memory of Dr. S, the professor who gave me that lecture.^[1]

That class was scheduled for an afternoon during my surgical rotation, back in 2015. Other medical students and I were seated in a small conference room at Hospital La Misericordia (“Mercy Hospital”), recognized as Colombia’s first pediatric hospital. Dr. S – an emeritus professor and one of the most prominent figures in Colombian pediatric surgery – walked in and pulled up his slides. What I could not predict was that Dr. S’s lecture would stay with me as a record of physicians’ personal experiences with the evolution of intersex medicine in Colombia. It would also be a reminder that even when medical standards feel like a fully legitimate shelter, they can change at any moment and leave lasting harm in patients’ lives and physicians’ careers.

Dr. S began his lecture by situating pediatric surgery within Colombia’s medical history. The surgical care for children, he explained, was rooted in the philanthropic acts of wealthy people from the nineteenth century. These acts led to the founding of institutions such as Hospital La Misericordia in 1906, to care for orphaned and impoverished children.^[2] In Dr. S’s words, caridad (“compassion”) prompted mid-twentieth-century pediatricians and general surgeons working in those institutions to attend to children with surgical conditions.^[3] The mortality rate for those interventions was high, though, making it an urgent national priority to reduce death rates among children needing surgery.^[4]

Because there were no formally trained pediatric surgeons in Colombia, pioneering physicians had to travel abroad to specialize. The United States emerged as a central destination for such training because pediatric surgery had been institutionalized since the 1920s.^[5] The country’s growing prestige in the field coincided with a reorientation of Colombian medical education from European models to U.S. models after World War II.^[6] As a result, physicians, including Dr. S, traveled to the United States or Hispanic countries with the American medical education model to learn pediatric surgery.

On the next slide of the lecture presentation, an old photo of a man appeared. Dr. S explained that his surgical training at Hospital Infantil de México (Children’s Hospital of Mexico) was deeply influenced by that man, a psychologist named John Money.^[7] At Johns Hopkins Hospital, Money proposed a cutting-edge theory that gender identity and gender roles were not established at birth but were formed within the first two years.^[8] Even though Money wasn’t the only author of this theory, his name had, at that moment, become deeply entangled in Dr. S’s mind with the treatment of intersex children. This was largely because Money’s theory recommended assigning a definitive sex to children with intersex variations as early as possible and, ideally, surgically reconstructing the external genitals to match the assignment within a very short time window.^[9]

This transnational shift in gender understanding became part of the surgical protocols Dr. S learned. He brought them back to Colombia in the 1960s when he began his career as one of the country’s first pediatric surgeons. Eventually, he helped establish the specialty at Hospital La Misericordia and trained generations of students in emerging surgical techniques.^[10] Among his lessons was the idea that intersex variations constituted both a medical and social emergency – a condition that demanded rapid and decisive intervention. During the following decades, he and his team performed multiple “reassignment” surgeries guided by the American medical protocols, which were the authorities on intersex care by then.

However, the thing about standards, as all medical doctors learn eventually, is that they are not set in stone. Money’s theory became discredited between the 1980s and 1990s. One of the main reasons was the outright failure of Money’s John/Joan experiment. “John” was the pseudonym given to a baby who, during a circumcision, had his penis severely burned because of a technical accident. His parents met Money at Johns Hopkins and, following his advice, “John” had surgically removed what remained of his penis and was raised as a girl, becoming known by the pseudonym of “Joan.” Since “Joan” had a twin brother, Money followed the siblings and wrote about this case as a big success, proving his supposition that gender identity owed more to “nurture” than “nature.” By the 1980s, however, a BBC documentary and the investigation by the sexologist Milton Diamond uncovered the case of “Joan.”^[11] It turned out that “Joan” never felt comfortable with his gender identity and, after learning about his accident as a baby, rejected the assigned female identity, transitioned to male, and became known as David Reimer.^[12] The result was that Money’s once-celebrated case, which supposedly proved that gender wasn’t related to biology, ended up being part of the reason he became publicly recriminated.

In a parallel scenario, Dr. S also had to endure an episode of public accusation of malpractice in intersex care during his senior years. As he related to us during the class, a popular Colombian investigative journalism television program called Séptimo día (“Seventh day”) aired an episode in 2011 revisiting the case of a Dr. S’s former intersex patient. He was born with an intersex variation and underwent a sex reassignment surgery. During the broadcast, the patient revealed he was experiencing profound distress after discovering his biological history, and Dr. S was confronted on camera by a journalist, who publicly accused him of “playing God.” Dr. S finished his narration with a phrase I maintain fresh in my mind:

“You must understand, I wasn’t deciding the sex of the intersex patients by myself; I was guided by the medical care standard of the time.”

That faithful adherence to the standards ignited a public debate over the episode that lasted over a month and included several formal complaints from the numerous medical associations of the country. It ended with the program’s retraction.

That same afternoon, I went home after class with Dr. S and searched online. I watched the full episode and its retraction. I read the complaint letters issued by Hospital La Misericordia, the Colombian Society of Pediatric Surgery, and the Colombian Association of Surgery in response to the broadcast. I also read the heated debates among students and patients on social media at the time. Today, those materials are no longer accessible. What remains are only faint traces, scattered references such as a blog recounting the episode, an opinion letter in a newspaper complaining about the event, and some fragmented digital archives accessible through resources such as Wayback Machine. Without having witnessed them myself, it would be easy to believe that the events recounted by Dr. S never happened.

After the 1990s, multiple stories of surgically reassigned patients whose assigned gender didn’t match their actual gender identity surfaced. Stories like Santiago’s are examples of how history returns to question medicine. Even with the record of controversies erased, the friction between the standard approved by medical authorities and its consequences in people’s bodies persisted. For us physicians, that is a permanent reminder that our lifelong commitment should not be to the standard but to our patients’ well-being. And how can patients’ well-being be achieved if their own experiences are not considered?

That question was also present in another part of Dr. S’s history with Colombian intersex care. One of the last slides of his presentation that afternoon had a tiny inscription: “SU-337-99 ruling.”^[13] That ruling resulted from Colombian controversies and legal precedents regarding intersex care in the 1990s.^[14] Eventually, the emblematic case of a group of physicians who refused to perform a sex reassignment surgery on an intersex minor, despite the mother’s request, reached the Colombian Constitutional Court.

Defying prevailing biomedical models, the Colombian Court conducted its own extensive, unprecedented consultation with medical experts, psychiatrists, and intersex rights organizations. That analysis concluded that genital ambiguity was not a medical emergency and that irreversible procedures cannot be justified based on the social discomfort of parents or health staff. By affirming that no one – not even parents – can make such decisions on behalf of a minor, the Court established the boundaries of medical authority and parental consent by prioritizing patient autonomy.^[15] It became one of the first judicial decisions worldwide to regulate informed consent in intersex minors and has since been widely cited internationally in both the law and in bioethical debates.^[16]

Because of Dr. S’s expertise in pediatric care – including intersex “care” – and his status as one of the country’s leading authorities in pediatric surgery, the Court called on him in 1997 to present his views during its deliberations.^[17] In that role, Dr. S acknowledged that physicians could now recognize different definitions of sex and identity and that surgical sex reassignment, being a non-life-saving procedure, should take into account patients’ insights. By reframing intersex care less as a surgical “emergency” in which a physician should decide immediately the sex of the person, and more as a question of patients’ autonomy, he became part of the legal and bioethical transformation of intersex medicine in Colombia and beyond.^[18] Notably, this later change in his framing was not included in the 2011 television program.

More than a decade later, I still remember Dr. S’s class. That afternoon, I learned for the first time about intersex variations. But I also learned, through Dr. S’s account of his own career, how transnational standards, once treated as unquestionable, could later be challenged in public debate. That became a milestone in my training and transformed into an enduring lesson. Following the “standard of care” does not shield physicians from responsibility. When standards fail to account for patients’ life experiences, they risk crashing with medicine’s oldest command: primum non nocere. First, do no harm.

Notes

1. A pseudonym is used because the experience of Dr. S is presented not as an isolated individual case, but as an example that represents the historical transformations in intersex care practices in Colombia. ↑
2. Efraim Bonilla, «La cirugía pediátrica, una obra de caridad», Revista Colombiana de Cirugía 28 (2013): 266-70. ↑
3. Efraim Bonilla, La Cirugía Pediátrica, Una Obra de Caridad (2013). ↑
4. Bernardo Ochoa, Invited overseas lecture. Pediatric Surgery in Latin America, 37, n.^o 7 (2000): 1026-30, https://doi.org/10.1053jpsu.2000.7764; Instituto Nacional de Salud, La Mortalidad en Colombia 1953-1991, Instituto Nacional de Salud (Bogotá, 1993). ↑
5. Judson G. Randolph, «Notes on the Early Development of Pediatric Surgery in the United States», Journal of Pediatric Surgery 47, n.^o 1 (2012): 10-16, https://doi.org/10.1016/j.jpedsurg.2011.10.012. ↑
6. Bernardo Ochoa, Invited overseas lecture Pediatric Surgery in Latin America, 2000, https://doi.org/10.1053/js.2000.7764. ↑
7. Jorge Padrón, «Homenaje al profesor Efraím Bonilla Arciniegas», Semblanzas del departamento Quirúrgico, Fundación Santa Fe de Bogotá, 2021. ↑
8. Money J et al., «Hermaphroditism: Recommendations concerning case management», Bulletin of the Johns Hopkins Hospital 97, n.^o 4 (1955): 284-300. ↑
9. Money J et al., «Hermaphroditism: Recommendations concerning case management», Bulletin of the Johns Hopkins Hospital 97, n.^o 4 (1955): 284-300. ↑
10. Padrón, «Homenaje al profesor Efraím Bonilla Arciniegas». ↑
11. BBC World Service, «Health Check: The boy who was raised a girl», News, BBC World Service, 2010, https://www.bbc.com/news/health-11814300. ↑
12. Anne Fausto-Sterling, Sexing the Body: Gender Politics and the Construction of Sexuality (Basic Books, 2000). ↑
13. Corte Constitucional de Colombia, Sentencia SU-337/99 (1999), http://www.isna.org/node/166. ↑
14. Corte Constitucional Colombiana, «Sentencia No. T-477/95», 1995. ↑
15. Diana Patricia Tovar, «Desarrollo jurisprudencial de la intersexualidad: consentimiento informado, infancia y derechos», Debate Feminista 47 (2013): 3-353. ↑
16. Cheryl Chase, «Background of Colombia Decisions», Intersex Society of North America, 1999, https://isna.org/node/21/; Miguel Ángel Grez Catalán, «Las personas intersexuales frente al derecho: estudio exploratorio de tres problemas jurídicos.» (Universidad de Chile, 2020). ↑
17. Corte Constitucional de Colombia, Sentencia SU-337/99 (1999), http://www.isna.org/node/166. ↑
18. Corte Constitucional de Colombia, Sentencia SU-337/99. ↑

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Featured image caption: The Colombian flag. (Courtesy Jose Vasquez)