Christoph Rehmann-Sutter

Institute for the History of Medicine and Science Studies, University of Lübeck

When considering surgical interventions for children with variations in sex development, complex ethical questions arise. When is the right time in the life of the child or future adolescent to make this decision? International recommendations (Endo-ERN 2026 and Council of Europe 2025), as well as national law in Germany (Section 1631e of the German Civil Code – ‘prohibition on surgery’) require that, in the case of children with variations in sex development, surgical interventions on the genitals – unless they are urgent or immediately necessary to avert a danger to life or health – be deferred until the person is able to decide for themselves.

However, this is not merely a matter of ensuring informed consent, which only becomes possible once a certain level of maturity has been reached during puberty and the child’s ongoing sexual development. When choosing the timing, alongside medical considerations regarding the course and optimisation of the procedures, (i) the perspective of concerned parents and their visions for their child’s future, (ii) and (iii) the child’s own perspective all play a key role. The timing of decisions is perceived differently from these perspectives, which leads to conflicts. However, the requirement to act in the best interests of the child places the child’s subjectivity at the centre.

Decisions are made (iv) within a historical context. The history of medical practice has been shaped by shifting paradigms: John Money’s ‘gender’ approach in the 1950s, the rise of self-help organisations since the 1990s, the reassessment within the medical profession (from the Chicago Conference in 2005 to the latest guidelines in paediatric endocrinology), as well as the new legal protection of the self-determination of those affected. Intersex studies are re-examining this history (Monro, Berry, Carpenter, Crocetti and Wall 2025). Linked to this is a societal shift towards greater openness in the gender system, which makes gender positions possible even beyond the binary.

This paper explores the differently perceived temporalities and relates them to one another. The aim is to develop a matrix of ethical assessment dimensions for the best interests of the child in individual cases, which can support the assessment carried out by interdisciplinary commissions and family courts under Section 1631e of the German Civil Code (BGB). Self-determination is contextualised in terms of both time and society.