Copyright C 2ooo by Anne Fausto-Sterling

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All uncredited illustrations are from the author's collection and are used with her permission.
First Edition
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3
OF GE NDE R A ND GE NI TA L S :
THE USE AND ABUSE OF THE MODERN INTERSEXUAL
y
x
Conf r ont i ng t he I nt e r s e x Ne wbor n
.ni rc.rs
Acnrrr rs rr r . r.rci i.rrrr.. nsrr..r r .ni Ur.ir
States or Western Europe. The attending physician, realizing that the new-
borns genitalia are either/or, neither/both, consults a pediatric endocrinolo-
gist (childrens hormone specialist) and a surgeon. They declare a state of
medical emergency.
1
According to current treatment standards, there is no
time to waste in quiet reection or open-ended consultations with the par-
ents. No time for the new parents to consult those who have previously given
birth to mixed-sex babies or to talk with adult intersexuals. Before twenty-
four hours pass, the child must leave the hospital as a sex, and the parents
must feel certain of the decision.
Why this rush to judgment? Howcan we feel so certain within just twenty-
four hours that we have made the right assignment of sex to a newborn?
2
Once
such decisions are made, how are they carried out and how do they aect the
childs future?
Since the .,-s, psychologists, sexologists, and other researchers have
battled over theories about the origins of sexual dierence, especially gender
identity, gender roles, and sexual orientation. Much is at stake in these de-
bates. Our conceptions of the nature of gender dierence shape, even as they
reect, the ways we structure our social system and polity; they also shape
and reect our understanding of our physical bodies. Nowhere is this clearer
than in the debates over the structure (and restructuring) of bodies that ex-
hibit sexual ambiguity.
Oddly, the contemporary practice of xing intersex babies immediately
after birth emerged from some surprisingly exible theories of gender. In the
.,,-s, Albert Ellis studied eighty-four cases of mixed births and concluded
46 S i x r c . ni Br
that while the power of the human sex drive may possibly be largely dependent
on physiological factors . . . the direction of this drive does not seem to be
directly dependent on constitutional elements.
3
In other words, in the devel-
opment of masculinity, femininity, and inclinations toward homo- or hetero-
sexuality, nurture matters a great deal more than nature. A decade later, the
Johns Hopkins psychologist John Money and his colleagues, the psychiatrists
John and Joan Hampson, took up the study of intersexuals, whom, Money
realized, would provide invaluable material for the comparative study of
bodily form and physiology, rearing, and psychosexual orientation.
4
Agree-
ing with Elliss earlier assessment, Money and his colleagues used their own
studies to state in the extreme what these days seems extraordinary for its
complete denial of the notion of natural inclination. They concluded that go-
nads, hormones, and chromosomes did not automatically determine a childs
gender role: Fromthe sumtotal of hermaphroditic evidence, the conclusion
that emerges is that sexual behavior and orientation as male or female does
not have an innate, instinctive basis.
5
Did they then conclude that the categories male and female had no
biological basis or necessity? Absolutely not. These scientists studied her-
maphrodites to prove that nature mattered hardly at all. But they never ques-
tioned the fundamental assumption that there are only two sexes, because
their goal in studying intersexuals was to nd out more about normal devel-
opment.
6
Intersexuality, in Moneys view, resulted from fundamentally ab-
normal processes. Their patients required medical treatment because they
ought to have become either a male or a female. The goal of treatment was to
assure proper psychosexual development by assigning the young mixed-sex
child to the proper gender and then doing whatever was necessary to assure
that the child and h/her parents believed in the sex assignment.
7
By .,t,, when Christopher Dewhurst (Professor of Obstetrics and Gyne-
cology in London at the Queen Charlotte Maternity Hospital and the Chelsea
Hospital for Women) and Ronald R. Gordon (Consultant Pediatrician and
Lecturer in Child Health at Sheeld University) wrote their treatise on The
Intersexual Disorders, medical and surgical approaches to intersexuality neared
a state of hitherto unattained uniformity. It seems hardly surprising that this
coalescence of medical views occurred during the era that witnessed what
Betty Friedan dubbed the feminine mystiquethe postWorld War II ideal
of the suburban family structured around strictly divided gender roles. That
people failed to conform fully to this ideal can be gleaned from the near hys-
terical tone of Dewhurst and Gordons book, which contrasts markedly with
the calm and reason of Youngs founding treatise.
O f G e n d e r a n d G e n i t a l s 47
rrcri ..: A six-day old XX child with masculinized external genitalia.
(Original photo by Lawson Wilkins in Young .,t. [gure .., p. .,-]; reprinted with
permission, Williams and Wilkins)
Dewhurst and Gordon open their book with a description of a newborn
intersexual child, accompanied by a close-up photograph of the babys geni-
tals. They employ the rhetoric of tragedy: One can only attempt to imagine
the anguish of the parents. That a newborn should have a deformity . . .
(aecting) so fundamental an issue as the very sex of the child . . . is a tragic
event which immediately conjures up visions of a hopeless psychological mist
doomed to live always as a sexual freak in loneliness and frustration.
They warn that freakhood will, indeed, be the babys fate should the case
be improperly managed, but fortunately, with correct management the out-
look is innitely better than the poor parentsemotionally stunned by the
eventor indeed anyone without special knowledge could ever imagine.
48 S i x r c . ni Br
Luckily for the child, whose sweet little genitalia we are invited to examine
intimately (gure ..), the problem was faced promptly and eciently by
the local pediatrician. Ultimately, readers learn, the parents received assur-
ance that despite appearances, the baby was really a female whose external
genitalia had become masculinized by unusually high levels of androgen pres-
ent during fetal life. She could, they were told, have normal sexual relations
(after surgery to open the vaginal passageway and shorten the clitoris) and
even be able to bear children.
8
Dewhurst and Gordon contrast this happy outcome with that of incorrect
treatment or neglect through medical ignorance. They describe a fty-year-
old who had lived h/her life as a woman, again treating the reader to an inti-
mate close-up of the patients genitalia,
9
which shows a large phallic-like clito-
ris, no scrotum, and separate urethral and vaginal openings. S/he had worried
as a teenager about her genitals and lack of breasts and menstruation, the
doctors report, but had adjusted to her unfortunate state. Nevertheless,
at age fty-two the doubts returned to torment h/her. After diagnosing
h/her as a male pseudo-hermaphrodite, doomed to the female sex assignment
in which she had lived unhappily, Dewhurst and Gordon noted that the case
illustrated the kind of tragedy which can result from incorrect manage-
ment.
10
Their book, in contrast, is meant to provide the reader (presumably
other medical personnel) with lessons in correct management.
Today, despite the general consensus that intersexual children must be cor-
rected immediately, medical practice in these cases varies enormously. No
national or international standards govern the types of intervention that may
be used. Many medical schools teach the specic procedures discussed in this
book, but individual surgeons make decisions based on their own beliefs and
what was current practice when they were in trainingwhich may or may
not concur with the approaches published in cutting-edge medical journals.
Whatever treatment they choose, however, physicians who decide how to
manage intersexuality act out of, and perpetuate, deeply held beliefs about
male and female sexuality, gender roles, and the (im)proper place of homo-
sexuality in normal development.
.ni r.ri.s
When a mixed-sex child is born, somebody (sometimes the surgeon, some-
times a pediatric endocrinologist, more rarely a trained sex education coun-
selor) explains the situation to the parents.
11
A normal boy, they say, may
be born with a penis (dened as a phallus that has a urethral tube [through
which urine ows] running lengthwise through its center and opening at
the tip). This boy also has one X and one Y chromosome (XY), two testes
O f G e n d e r a n d G e n i t a l s 49
labia majora
labia minora
clitoris
urethra
vagina
clitoris
urethra
vagina
anus
cervix
bladder
uterus
ovary
fallopian tube
anus
scrotum
epididymis
bladder
testis
anus
vas deferens
erectile tissues
glans penis
urethra
A: Female Reproductive Anatomy B: Male Reproductive Anatomy
.: A: Female reproductive anatomy. B: Male reproductive anatomy.
(Source: Alyce Santoro, for the author)
descended into scrotal sacs, and a variety of tubing, which in the sexually
mature male transports sperm and other components of the seminal uid to
the outside world (gure .B).
Just as often, the child has a clitoris (a phallus that does not have a urethra)
which, like a penis, contains ample supplies of blood and nerves. Physical
stimulation can cause both to become erect and to undergo a series of con-
tractions that we call orgasm.
12
In a normal girl the urethra opens near the
vagina, a large canal surrounded at its opening by two sets of eshy lips. The
canal walls connect on the inside to the cervix, which in turn opens up into
the uterus. Attached to the uterus are oviducts, which, after puberty, trans-
port egg cells from the nearby pair of ovaries toward the uterus and beyond
(gure .A). If this child also has two X chromosomes (XX), we say she
is female.
The doctors will also explain to the parents that male and female embryos
develop by progressive divergence froma common starting point (gure .).
The embryonic gonad makes a choice early in development to follow a male
or female pathway, and later in development the phallus ends up as either a
clitoris or a penis. Similarly, the embryonic urogenital swellings either remain
open to become vaginal labia or fuse to become a scrotum. Finally, all embryos
contain structures destined to become the uterus and fallopian tubes and ones
with the potential to become the epididymis and vas deferens (both are tubu-
lar structures involved with transporting sperm from the testes to the bodys
50 S i x r c . ni Br
rrcri .: The development of external genitalia from the embryonic period through
birth. (Source: Redrawn by Alyce Santoro from Moore .,,,, p. ,., with permission from W. B. Saunders)
exterior). When the sex is chosen, the appropriate structures develop and the
rest degenerate.
So far, so good. The doctors have simply recounted some basics of embry-
ology. Now comes the tricky part: what to tell the parents of a child whose
development has not proceeded along the classic path. Generally doctors in-
form parents that the infant has a birth defect of unnished genitalia, and
that it may take a little time before theyll know whether the child is a boy or
a girl.
13
The doctors can and will, they assure the parents, identify the true
sex that lies underneath the surface confusion. Once they do, their hormonal
and surgical treatments can complete natures intention.
14
Modern medical practitioners still use the nineteenth-century categories
of true and male pseudo or female pseudo hermaphrodites.
15
Since
most intersexuals fall into the pseudo category, doctors believe that an inter-
sexual child is really a boy or a girl. Money, and others trained in his ap-
proach, specically ban the word hermaphrodite from use in conversation with
O f G e n d e r a n d G e n i t a l s 51
the parents. Instead, doctors use more specic medical terminologysuch
as sex chromosome anomalies, gonadal anomalies, and external organ
anomalies
16
that indicate that intersex children are just unusual in some
aspect of their physiology, not that they constitute a category other than male
or female.
The most common types of intersexuality are congenital adrenal hyperpla-
sia (CAH), androgen insensitivity syndrome (AIS), gonadal dysgenesis, hypo-
spadias, and unusual chromosome compositions such as XXY (Klinefelter
Syndrome) or XO (Turner Syndrome) (see table .). So-called true her-
maphrodites have a combination of ovaries and testes. Sometimes an individ-
ual has a male side and a female side. In other cases the ovary and testis grow
together in the same organ, forming what biologists call an ovo-testis.
17
Not
infrequently, at least one of the gonads functions quite well (the ovary more
often than the testis),
18
producing either sperm or eggs and functional levels
of the so-called sex hormonesandrogens or estrogens. In theory, it might
be possible for a hermaphrodite to give birth to h/her own child, but there is
no recorded case of that occurring. In practice, the external genitalia and
accompanying genital ducts are so mixed that only after exploratory surgery
is it possible to know what parts are present and what is attached to what.
19
Parents of intersexuals often ask how frequently children like theirs are
born and whether there are any parents of similar children with whom they
might confer. Doctors, because they generally view intersex births as urgent
cases, are unaware of available resources themselves, and because the medical
research is scanty, often simply tell parents that the condition is extremely
rare and therefore there is nobody in similar circumstances with whom they
can consult. Both answers are far from the truth. I will return to the question
of support groups for intersexuals and their parents in the next chapter. Here
I address the question of frequency.
Howoften are intersex babies born? Together with a group of Brown Uni-
versity undergraduates, I scoured the medical literature for frequency esti-
mates of various categories of intersexuality.
20
For some categories, usually
the rarest, we found only anecdotal evidence. But for most, numbers exist.
The gure we ended up with. percent of all births (see table .)
should be taken as an order-of-magnitude estimate rather than a precise
count.
21
Even if weve overestimated by a factor of two, that still means a lot of
intersexual children are born each year. At the rate of . percent, for exam-
ple, a city of , would have , people with varying degrees of inter-
sexual development. Compare this with albinism, another relatively uncom-
mon human trait but one that most readers can probably recall having seen.
52
TABLE 3 . 1 Some Common Types of Intersexuality
.i c.si r.src crrrc.r ri..ris
Congenital Genetically inherited In XX children, can cause mild to se-
Adrenal malfunction of one or vere masculinization of genitalia at
Hyperplasia more of six enzymes in- birth or later; if untreated, can cause
(CAH) volved in making steroid masculinization at puberty and early pu-
hormones berty. Some forms drastically disrupt
salt metabolism and are life-threaten-
ing if not treated with cortisone.
Androgen Genetically inherited XY children born with highly femi-
Insensitivity change in the cell surface nized genitalia. The body is blind to
Syndrome receptor for testosterone the presence of testosterone, since cells
(AIS) cannot capture it and use it to move de-
velopment in a male direction. At pu-
berty these children develop breasts
and a feminine body shape.
Gonadal Various causes, not all Refers to individuals (mostly XY)
Dysgenesis genetic; a catch-all whose gonads do not develop properly.
category Clinical features are heterogeneous.
Hypospadias Various causes, including The urethra does not run to the tip of
alterations in testoster- the penis. In mild forms, the opening is
one metabolism
a
just shy of the tip; in moderate forms,
it is along the shaft; and in severe
forms, it may open at the base of the
penis.
Turner Females lacking a second A form of gonadal dysgenesis in fe-
Syndrome X chromosome. (XO)
b
males. Ovaries do not develop; stature
is short; lack of secondary sex charac-
teristics; treatment includes estrogen
and growth hormone.
Klinefelter Males with an extra X A form of gonadal dysgenesis causing
Syndrome chromosome (XXY)
c
infertility; after puberty there is often
breast enlargement; treatments include
testosterone therapy.
a. Aaronson et al. .,,,.
b. The story is, of course, more complicated. For some recent studies, see Jacobs, Dalton, et al.
.,,,; Boman et al. .,,-.
c. There are a great many chromosomal variations classied as Klinefelter (Conte and Grumbach
.,-,).
Of Ge n d e r a n d Ge n i t a l s 53
TABLE 3 . 2 Frequencies of Various Causes
of Nondimorphic Sexual Development
is.r..ir rriic/
c.si .-- rri rrr.ns
Non-XX or non-XY (except Turners or Klinefelters) -.-t,
Turner Syndrome -.-t,
Klinefelter Syndrome -.-,
Androgen Insensitivity Syndrome -.--,t
Partial Androgen Insensitivity Syndrome -.---,t
Classic CAH (omitting very high-frequency population) -.--,,,
Late-onset CAH ..
Vaginal agenesis -.-.t,
True hermaphrodites -.--.
Idiopathic -.---,
...r ..,-
Albino births occur much less frequently than intersexual birthsin only
about . in -,--- babies.
22
The gure of .., percent is an average from a wide variety of populations;
the number is not uniformthroughout the world. Many forms of intersexual-
ity result from an altered genetic state, and in some populations, the genes
involved with intersexuality are very frequent. Consider, for example, the
gene for congenital adrenal hyperplasia (CAH). When present in two doses
(that is, when an individual is homozygous for the gene), it causes XXfemales
to be born with masculinized external genitalia (although their internal re-
productive organs are those of a potentially fertile woman) (see table ..).
The frequency of the gene for CAH varies widely around the world. One
study found that . per thousand Yupik Eskimos born had a double dose of
the CAH gene. In contrast, only -.--/.,--- New Zealanders express the
trait. The frequency of a related genetic change that leaves the genitalia un-
aected but can cause premature pubic hair growth in children and symptoms
such as unusual hair growth and male pattern baldness in young women, also
54 S i x r c . ni Br
varies widely around the world. These altered genes result in symptoms in
/.,--- Italians. Among Ashkenazic Jews, the number rises to ,/.,---.
23
Furthermore, the incidence of intersexuality may be on the rise. There
has already been one medical report of the birth of a child with both an ovary
and testes to a mother who conceived via in vitro fertilization. It seems that
two embryos, one XX and one XY, fused after three were implanted into her
uterus. Save for the ovary, the resulting fetus was a normal, healthy boy,
formed from the fusion of an XX and an XY embryo!
24
There is also concern
that the presence of environmental pollutants that mimic estrogen have begun
to cause widespread increases in the incidence of intersex forms such as hypo-
spadias.
25
But if our technology has contributed to shifts in our sexual makeup, it
nevertheless also provides the tools to negate those changes. Until very re-
cently, the specter of intersexuality has spurred us to police bodies of indeter-
minate sex. Rather than force us to admit the social nature of our ideas about
sexual dierence, our ever more sophisticated medical technology has al-
lowed us, by its attempts to render such bodies male or female, to insist that
people are either naturally male or female. Such insistence occurs even though
intersexual births occur with remarkably high frequency and may be on the
increase. The paradoxes inherent in such reasoning, however, continue to
haunt mainstreammedicine, surfacing over and over in both scholarly debates
and grassroots activism around sexual identities.
Fi x i ng I nt e r s e x ual s
.ni rri...r rrx
To produce gender-normal children, some medical scientists have turned to
prenatal therapy. Biotechnology has already changed the human race. We
have, for example, used amniocentesis and selective abortion to lower the
frequency of Down Syndrome births, and in some parts of the world we have
even altered the sex ratio by selectively aborting female fetuses,
26
and now
both the sonogram and amniotic testing of pregnant women can detect signs
of the babys gender as well as a wide variety of developmental problems.
27
Most types of intersexuality cannot be changed by prenatal interventions, but
one of the most frequent kindsCAHcan. Is this a good thing? Howmight
the elimination of a major cause of genital ambiguity aect our understanding
of that which qualies a body for life within the domain of cultural intelligi-
bility?
28
The genes that cause CAH are well characterized, and several approaches
to detecting their presence in the embryo nowexist.
29
Awoman who suspects
O f G e n d e r a n d G e n i t a l s 55
she may be pregnant with a CAHbaby (if she or someone in her family carries
CAH) can undergo treatment and then get tested. I put it in that order, be-
cause to prevent masculinization of an XX-CAH childs genitalia, treatment
(with a steroid called dexamethasone) must begin as early as four weeks after
conception.
30
The earliest methods for diagnosis, however, cant be used until
the ninth week.
31
For every eight fetuses treated for CAH, only one will actu-
ally turn out to be an XX child with masculinized genitals
32
. If it turns out
that the fetus is a male (physicians are not worried about male masculiniza-
tionyou can never, apparently be too masculine)
33
or does not have CAH,
treatment can be discontinued.
34
If, however, the fetus is XX and is aected
by CAH, the mother and fetus continue dexamethasone treatment for the
duration of the pregnancy.
35
It might sound like a good idea, but the data are slim. One study compared
seven untreated CAH girls (born with masculinized genitals) with their pre-
natally treated sisters. Three were born with completely female genitals,
while four were only mildly masculinized compared with their siblings.
36
An-
other study of ve CAH girls reported considerably more feminine genital
development.
37
In medicine, however, everything has a price. The diagnostic
tests
38
stand a to percent chance of inducing miscarriage, and the treat-
ment produces side eects in both mother and child: mothers may retain u-
ids, gain a lot of extra weight, develop hypertension and diabetes, have in-
creased and permanent scarring along abdominal stretch lines, grow extra
facial hair, and become more emotional. The eect on fetal metabolism is
not known,
39
but one recent study reports negative eects such as failure to
thrive and delayed psychomotor development. Another research group found
that prenatal dexamethasone treatment may cause a variety of behavioral
problems, including increased shyness, less sociability, and greater emo-
tionality.
40
Today many still do not advocate such treatment because the safety of
this experimental therapy has not been established in rigorously controlled
trials.
41
On the other hand, prenatal diagnosis allows physicians to recognize
the metabolic alterations and begin treatment at birth. Early and continuous
treatment can prevent possible salt-wasting crises (which endanger the childs
life) and address other CAH-related problems, such as premature growth
stoppage and extremely early puberty. This also benets XY CAH kids, since
they still have the metabolic problems, even if their genitals are ne. Finally,
genital surgery on XX CAH children can be eliminated or minimized.
Parents have given prenatal therapy mixed reviews. In one study of
pregnancies, parents accepted prenatal treatment after being apprised of
the pros and cons, while seventy-ve refused the treatment. Fifteen of the
56 S i x r c . ni Br
seventy-ve had CAH fetuses (eight XX and seven XY), and parents chose to
abort three of the untreated XX fetuses.
42
In another study, researchers sur-
veyed - mothers attitudes after experiencing treatment. Although each
woman had severe side eects and was concerned about the possible short-
and long-term eects of dexamethasone on her child and herself, each said
she would do it again to avoid giving birth to a girl with masculine genitals.
43
Prenatal diagnosis seems warranted because it can prepare physicians and
parents alike for the birth of a child whose chronic medical problems will
demand early hormonal treatment. Whether prenatal therapy is ready for
prime time is another question. To put it starkly: Are seven unnecessary treat-
ments, with their attendant side eects worth one less virilized girl child? If
you believe that virilization requires extensive reconstructive surgery in order
to avoid damage to the childs mental health, the answer will probably be
yes.
44
If, however, you believe that many of the surgeries on CAH children
are unnecessary, then the answer might well be no. Perhaps compromises are
possible. If one could lessen the side eects of dexamethasone treatment by
limiting it to the period of initial genital formation, this would probably alle-
viate the most severe genital problems, such as fusion of the labia, but might
not halt clitoral enlargement. Surgeries involving fused labia and reconstruc-
tion of the urogenital sinus are complex, not always successful, and essential
if the aected individual wants to bear children. All other things being equal,
it would seem best to avoid such surgery. As I argue in the rest of this chapter
and the next, however, downsizing an overgrown clitoris is simply not nec-
essary.
.ni srcrc.r rrx
If there has been no prenatal x and an intersex child is born, doctors must
decide, as they would put it, natures intention. Was the newborn infant sup-
posed to have been a boy or a girl? Dr. Patricia Donahoe, Professor of Surgery
at Harvard Medical School and a highly accomplished researcher in the elds
of embryology and surgery, has developed a rapid procedure for choosing an
ambiguous newborns gender assignment. First she ascertains whether the
newborn has two X chromosomes (is chromatin-positive) and then whether
the child has symmetrically placed gonads. She places a chromatin-positive
child with symmetrical gonads in the female pseudo-hermaphrodite box. In
contrast, she is likely to classify an XX child with asymmetrical gonads as a
true hermaphrodite, since the asymmetry most commonly reects the pres-
ence of a testis on one side and an ovary on the other.
Children with one X chromosome (chromatin-negative) can also be di-
vided into two groups: one with symmetrical and one with asymmetrical
O f G e n d e r a n d G e n i t a l s 57
gonads. Babies with gonadal symmetry who are chromatin-negative fall into
the male pseudo-hermaphrodite cubbyhole, while gonadally asymmetrical
chromatin-negatives receive the label mixed-gonadal dysgenesis, a catchall
category containing individuals whose potentially male gonads have some
form of abnormal development.
45
This stepwise decision tree, which uses the
permutations derived from the symmetry of gonads and the presence or ab-
sence of a second X, enables the physician to categorize the intersexual new-
born fast. Amore thorough and accurate assessment of the individuals specic
situation can take weeks or months.
Enough is known about each of the four categories (true, male pseudo,
female pseudo, and gonadal dysgenesis) to predict with considerable, although
not complete, accuracy how the genitalia will develop as the child grows and
whether the child will develop masculine or feminine traits at puberty. Given
such knowledge, medical managers employ the following rule: Genetic fe-
males should always be raised as females, preserving reproductive potential,
regardless of howseverely the patients are virilized. In the genetic male, how-
ever, the gender of assignment is based on the infants anatomy, predominantly
the size of the phallus.
46
Doctors insist on two functional assessments of the adequacy of phallus
size. Young boys should be able to pee standing up and thus to feel normal
during little-boy peeing contests; adult men, meanwhile, need a penis big
enough for vaginal penetration during sexual intercourse.
47
Howbig must the
organ be to fulll these central functions and thus t the denition of penis? In
one study of newborn males, penises ranged in length from . to .
centimeters (. to . inches).
48
Donahoe and her co-workers express
concern about a phallus of . centimeters, while one less than . centime-
ters long and . centimeters wide results in a female gender assignment.
49
In fact, doctors are not sure what to count as a normal penis. In an ideal
penis, for example, the urethra opens at the very tip of the glans. Suburethral
openings are often thought of as a pathology designated with the medical term
hypospadias. In a recent study, however, a group of urologists examined the
location of the urethral opening in men hospitalized for problems unre-
lated to hypospadias. Judged by the ideal penis, only percent of the men
were normal.
50
The rest had varying degrees of mild hypospadias, in which
the urethra opened near, but not at, the penis tip. Many never knew that they
had been urinating fromthe wrong place their entire lives! The authors of this
study conclude:
Pediatric urologists should be aware of the observed normal distribu-
tion of meatal [urethral] positions . . . since the aim of reconstructive
58 S i x r c . ni Br
surgery should be to restore the individual to normal. However, pure es-
thetic surgery would try to surpass the normal . . . this is the case in many
patients with hypospadias in whom the surgeon attempts to place the me-
atus in a position where it would not be found in ,% of so-called nor-
mal men.
51
The worries in male gender choice are more social than medical.
52
Physical
health is usually not an issue, although some intersexed babies might have
problems with urinary tract infection, which, if very severe, can lead to kid-
ney damage. Rather, early genital surgery has a set of psychological goals. Can
the surgery convince parents, caretakers, and peersand, through them, the
child him/herselfthat the intersexual is really a male? Most intersexual
males are infertile, so what counts especially is how the penis functions in
social interactionswhether it looks right to other boys, whether it can
perform satisfactorily in intercourse. It is not what the sex organ does for
the body to which it is attached that denes the body as male. It is what it does
vis-a`-vis other bodies.
53
Even our ideas about how large a babys penis needs
to be to guarantee maleness are fairly arbitrary. Perhaps unintentionally, Do-
nahoe drove home the social nature of the decision-making process when she
commented that phallus size at birth has not been reliably correlated with
size and function at puberty.
54
Thus, doctors may choose to remove a small
penis at birth and create a girl child, even though that penis may have grown
to normal size at puberty.
55
Deciding whether to call a child a boy or a girl, then, employs social de-
nitions of the essential components of gender. Such denitions, as the social
psychologist Suzanne Kessler observes in her book Lessons from the Intersexed,
are primarily cultural, not biological.
56
Consider, for instance, problems
caused by introducing European and American medical approaches into cul-
tures with dierent systems of gender. A group of physicians from Saudi Ara-
bia recently reported on several cases of XXintersex children with congenital
adrenal hyperplasia (CAH), a genetically inherited malfunction of the en-
zymes that aid in making steroid hormones. Despite having two X chromo-
somes, some CAH children are born with highly masculinized genitalia and
are initially identied as males. In the United States and Europe such children,
because they have the potential to bear children later in life, are usually raised
as girls. Saudi doctors trained in this European tradition recommended such
a course of action to the Saudi parents of CAH XX children. A number of
parents, however, refused to accept the recommendation that their child, ini-
tially identied as a son, be raised instead as a daughter. Nor would they accept
feminizing surgery for their child. As the reporting physicians write, female
O f G e n d e r a n d G e n i t a l s 59
.: Phall-o-Metrics. The ruler numbers indicate centimeters (not to
scale). (Source: Alyce Santoro, for the author)
upbringing was resisted on social grounds. . . . This was essentially an ex-
pression of local community attitudes with . . . the preference for male o-
spring.
57
If labeling intersex children as boys is tightly linked to cultural conceptions
of the maleness and proper penile function, labeling such children as girls is
a process even more tangled in social denitions of gender. Congenital adrenal
hyperplasia (CAH) is one of the most common causes of intersexuality in XX
children. CAHkids have the potential to become fertile females in adulthood.
Doctors often followDonahoes rule that reproductive function be preserved,
although Kessler reports one case of a physician choosing to reassign as male
a potentially reproductive genetic female infant rather than remove a well-
formed penis.
58
In principle, however, the size rule predominates in male as-
signment. One reason is purely technical. Surgeons arent very good at creat-
ing the big, strong penis they require men to have. If making a boy is hard,
making a girl, the medical literature implies, is easy. Females dont need any-
thing built; they just need excess maleness subtracted. As one surgeon well
known in this eld quipped, you can make a hole but you cant build a
pole.
59
As a teaching tool in their struggle to change the medical practice of infant
genital surgery, members of the Intersexual Rights Movement have designed
a phall-o-meter (shown in gure .), a small ruler that depicts the permis-
60 S i x r c . ni Br
TABL E 3 . 3 Recent History of Clitoral Surgery
# r rrrrsnir i.rs r ...r # r r..ri.s
.ri r srcir rirr.s rrrrc..r rirr.ir
Clitorectomy , .,.,,, .,
Clitoral Reduction - .,t..,, .
Clitoral Recession , .,,,.,, ,
Comparative Papers .,,,, .,- ,
a
Source: Extracted from data found in Rosenwald et al. .,-; Money .,t.; Randolf and Hung
.,,-; Randolf et al. .,-.; Donahoe and Hendren .,-,; Hampson .,; Hampson and Money
.,; Gross et al. .,tt; Lattimer .,t.; Mininberg .,-; Rajfer et al. .,-; van der Kamp et al.
.,,; Ehrhardt et al. .,t-; Allen et al. .,-; Azziz et al. .,-t; Newman et al. .,,b; Mulaikal
et al. .,-,; Kumar et al. .,,,; and Hendren and Crawford .,t,.
a. May include previously reported data.
sible ranges of phallus size for males and females at birth. It provides a graphic
summary of the reasoning behind the decision-making process for assigning
gender. If the clitoris is too big to belong to a girl, doctors will want to
downsize it,
60
but in contrast to the penis, doctors have rarely used precise
clitoral measurements in deciding the gender of a newborn child. Such mea-
surements, however, do exist. Since .,--, we have known that the average
clitoral size of newborn girls is -., centimeters.
61
More recent studies show
that clitoral length at birth ranges from -. to -.- centimeters.
62
One sur-
geon prominent in the eld of sex reassignment surgery, when interviewed in
.,,,, seemed unaware that such information existed. He also thought the
measurements irrelevant, arguing that for females overall appearance
counts rather than size.
63
Thus, despite published medical information show-
ing a range of clitoral size at birth, doctors may use only their personal impres-
sions to decide that a babys clitoris is too big to belong to a girl and must be
downsized, even in cases where the child is not intersexual by any denition.
64
Physicians ideas about the appropriate size and look of female genitals thus
sometimes leads to unnecessary and sexually damaging genital surgery.
65
Consider, for example, infants whose genitalia lie in that phallic limbo:
bigger than -.- but smaller than .- centimeters long (see gure .,). A
systematic review of the clinical literature on clitoral surgery from .,- to
the present reveals that although doctors have been consistent over the years
in assigning such infants to become female, they have radically shifted their
O f G e n d e r a n d G e n i t a l s 61
ideas about female sexuality and, consequently, their notions of appropriate
surgical treatment for female-intersex babies (see table .). In the early days
of surgical treatment, doctors performed complete clitorectomies on chil-
dren assigned to be females (the procedure is illustrated in gure .), reason-
ing that female orgasm was vaginal rather than clitoral.
66
During the .,t-s, physicians slowly began to acknowledge the clitoral
basis of female orgasm, although even today some surgeons maintain that the
clitoris is unnecessary for female orgasm.
67
In the sixties, then, physicians
turned to the procedures still used in some form today. In the operation
known as a clitoral reduction, the surgeon cuts the shaft of the elongated
phallus and sews the glans plus preserved nerves back onto the stump (gure
.t). In the less frequently used clitoral recession, the surgeon hides the clito-
ral shaft (referred to by one group of surgeons as the oending shaft)
68
under a fold of skin so that only the glans remains visible (gure .,).
Depending upon their anatomy at birth, some female-assigned children
face additional surgery: vaginal construction or expansion and labio-scrotal
reduction.
Intersex children assigned to become boys also face extensive surgery.
There are over -- surgical treatments described in the medical literature
for hypospadias, the opening of the urethra at some point along the shaft of
rrcri .: Removing the clitoris (clitorectomy).
(Source: Alyce Santoro, for the author)
62 S i x r c . ni Br
rrcri .t: Reducing the clitoris (clitoral reduction).
(Source: Alyce Santoro, for the author)
the penis rather than at its tip (necessitating that the child urinate sitting
down). Some of these operations address penile chordee, the binding of the
penis to the body by tissue, which causes it to curve and have diculty becom-
ing erecta condition that often results fromintersexual development.
69
Ex-
cept for the most minor forms of hypospadias all involve extensive suturing
and, on occasion, skin transplants. Amale-assigned child may receive as many
as three operations on the penis during the rst couple of years of life, and
even more by the time puberty hits. In the most severe cases, multiple opera-
tions can lead to densely scarred and immobile penises, a situation one physi-
cian has dubbed hypospadias cripple.
70
No consensus has formed about which technique consistently results in the
lowest complication rates and necessitates the fewest operations. The enor-
mous surgical literature on hypospadias is inconclusive. Every year dozens of
new papers appear describing new surgical techniques, each supposed to give
better results than the dozens of preceding techniques.
71
Many of the surgical
reports focus on special techniques for what the surgeons call secondary
operationsthat is, surgery designed to repair previously failed surgeries.
72
There are many reasons for the sprawling literature on hypospadias. The con-
dition is highly variable and thus calls for widely varied treatments. But a re-
O f G e n d e r a n d G e n i t a l s 63
rrcri .,: Hiding the clitoris (clitoral recession).
(Source: Alyce Santoro, for the author)
view of the literature also suggests that surgeons take particular pleasure in
pioneering new approaches to penile repair. Even medical professionals have
remarked on this obsession with penis-building. As one prominent urologist
who has a technique for hypospadias named after himself writes: Each hypo-
spadias surgeon has his fetishes.
73
.ni rscnrcrc.r rrx
Although inuential researchers such as John Money and John and Joan
Hampson believed that gender identity formation during early childhood is
extraordinarily malleable, they also thought that gender ambiguity later in
life was pathological. How, then, was an intersex infant to make the transition
from the open-ended possibilities present at birth to the xed gender identity
the medical establishment deemed necessary for psychological health? Be-
cause a childs psychological schema developed in concert with his or her body
image, Money and the Hampsons insisted, early genital surgery was impera-
tive. A childs body parts had to match his or her assigned sex. While such
anatomical clarity was important for the young child,
74
Money, the Hamp-
sons, and those who followed their lead argued, it was even more important
for the childs parents. As Peter Pan might have said, they had to believe in
64 S i x r c . ni Br
their childs gender identity for that identity to become real. Hampson and
Hampson write: In working with hermaphroditic children and their par-
ents, it has become clear that the establishment of a childs psychosexual ori-
entation begins not so much with the child as with his parents.
75
Ironically, in their extensive discussions about what not to tell parents,
medical practitioners reveal the logical bind they face when they try to explain
to patients and parents that the gender they have assignedand often per-
formed surgery to createis not arbitrarily chosen, rather, it is natural and
somehow inherent to the patients body all along. Thus developed a tradition
of gender doublespeak. Medical manuals and original research articles almost
unanimously recommend that parents and children not receive a full explana-
tion of an infants sexual status. Instead of saying that an infant is a mixture of
male and female, physicians are to allege that the intersex child is clearly
either male or female, but that embryonic development has been incomplete.
One physician writes: every eort should be made to discourage the concept
that the child is part male and part female. . . .This is often best handled by
explaining that the gonads were incompletely developed . . . and therefore
required removal. All eorts should be made to discourage any feeling of
sexual ambiguity.
76
A recent medical publication cautions that in counseling parents of inter-
sexual children, doctors must prevent contradictory or confusing informa-
tion fromadding to the uncertainty of the parents. . . . If the external genita-
lia of the child are unclear, the parents are only informed that the cause will
be investigated.
77
This group of Dutch physicians and psychologists often
treat androgen-insensitive (see table ..) children. AIS children have an Xand
an Y chromosome and active testes, but because their cells are insensitive to
testosterone, they cannot develop masculine secondary sex characteristics
and often respond at puberty to their own testicular estrogen by developing a
voluptuous female gure. Such children are generally raised as girls, both
because of their feminine body structure and because past experience has
shown that AIS children usually develop a female gender identity. Often the
AIS childs testes are removed but, caution the Dutch researchers, we speak
only about gonads, not testicles. If the gonad contains ovarian and testicular
tissue we say that the gonad is not entirely developed in a female direction.
78
Other physicians are aware that they must reckon with their patients
knowledge and curiosity. Because sex chromatin testing may be done in high
school biology courses and the media coverage of sexual medicine is increas-
ingly detailed, writes one group of researchers, one dare not assume that an
adolescent can be spared knowledge about his or her gonadal or chromosomal
status. But they also suggest that an XY intersex raised as a girl never be
O f G e n d e r a n d G e n i t a l s 65
told that she once had testes that were removed, emphasizing that nuanced
scientic understanding of anatomical sex is incompatible with a patients
need for clear-cut gender identity. An intersex child assigned to become a
girl, for instance, should understand any surgery she has undergone not as an
operation that changed her into a girl, but as a procedure that removed parts
that didnt belong to her as a girl. By convention the gonad is recorded as a
testis, these physicians write, but in the patients own formulation it is best
regarded as an imperfect organ . . . not suited to life as a female, and hence
removed.
79
Others believe that even this limited degree of openness is counterproduc-
tive. One surgeon suggests that accurate patho-physiological explanations
are not appropriate and medical honesty at any price is of no benet to the
patient. For instance, there is nothing to be gained by telling genetic males
raised as females about the maleness of their chromosomes or gonads.
80
In
their suggestions for withholding information about patients bodies and their
own decisions in shaping them, medical practitioners unintentionally reveal
their anxieties that a full disclosure of the facts about intersex bodies would
threaten individualsand by extension societysadherence to a strict
male-female model. I do not suggest a conspiracy; rather, doctors own deep
conviction that all people are either male or female renders themblind to such
logical binds.
Being coy about the truth in what doctors consider the interest of psycho-
logical health, however, can be at odds with sound medical practice. Consider
the controversy over the early removal of testes in AIS children. The reason
generally given is that the testes can become cancerous. However, the cancer
rates for testes of AIS patients dont increase until after puberty. And although
the androgen-insensitive body cannot respond to androgens made by the tes-
tes, it can and at puberty does respond to testicular estrogen production. Nat-
ural feminization may well be better than articially induced feminization,
especially with regard to the dangers of developing osteoporosis. So why dont
doctors delay removal of the testes until just after puberty? One reason is
surely that doctors might then have to tell a truer story to the AIS patient,
something they are extremely reluctant to do.
81
Kessler describes just such a case. A child received surgery when s/he was
too young to remember or fully understand the import of the changes in h/
her anatomy. When s/he reached puberty, doctors told her that she needed to
take estrogen pills for some time to come, explaining that her ovaries hadnt
been normal and had been removed. Apparently wishing to convince h/her
that her femininity was authentic despite her inability to have children, the
doctor explained that her uterus wont develop but [she] could adopt chil-
66 S i x r c . ni Br
dren. Another physician on the treatment team approved of his colleagues
explanation. Hes stating the truth, and if you dont state the truth . . . then
youre in trouble later. Given that the girl never had a uterus or ovaries,
however, this was, as Kessler points out, a strange version of the truth.
82
In recent years patients have had more than a little to say about such half-
truths and outright lies, and I will consider their viewpoints in the next chap-
ter. For now, I turn from the treatment protocols developed with an eye to-
ward keeping intersexuality within the bounds of a two-sex gender system,
to experimental studies conducted by physicians and psychologists on human
intersexuals. In the long tradition established by Saint-Hilaire, such investiga-
tions use intersexuality to reect on the normal development of masculin-
ity and femininity.
The Us e s of I nt e r s e x ual i t y
ricrc .ri/ricrc ri.ri
The underlying assumptions of the surgical approach to intersex babies have
not gone uncontested. Not everyone believes that sexual identity is funda-
mentally malleable. By far the most dramatic of these debates has been an
almost thirty-year battle between John Money and another psychologist, Mil-
ton Diamond. In the .,-s Money, together with his collaborators, the
Hampsons, argued that the sex assignment and sex of rearing predicted a her-
maphrodites adult gender role and sexual orientation more accurately than
did any aspect of h/her biological sex: Theoretically, our ndings indicate
[that] neither a purely hereditary nor a purely environmental doctrine of the
origins of gender role . . . is adequate. On the one hand it is evident that
gender role and orientation is not determined in some automatic, innate, in-
stinctive fashion by physical agents like chromosomes. On the other hand it is
also evident that the sex of assignment and rearing does not automatically and
mechanistically determine gender role and orientation.
83
But were Moneys claims applicable to the majority of sexually unambigu-
ous children? Had he and his colleaguesvia the study of intersex children
arrived at a general, possibly even universal, theory of psychosexual develop-
ment? Money believed he had, and to prove it he pointed to the case of an
unambiguously male child named John, who lost his penis at about seven
months of age after a circumcision accident. Reasoning from his studies on
intersexuals, Money counseled that the child be raised as a girl and surgically
altered to t her new status in life. A particularly compelling component of
this case was the fact that there was a control: Joan (as she was renamed) had
O f G e n d e r a n d G e n i t a l s 67
an identical twin brother. This case, Money hoped, would clinch his argument
about the importance of sex of rearing. If Joan developed a female gender
identity, while her genetically identical brother continued down the road
to adult masculinity, then environmental forces clearly trumped genetic
makeup.
The family ultimately agreed to the sex change, and by the time the child
reached her second year she had had feminizing surgery and her testicles had
been removed. With great delight, Money quoted Joans mother to the eect
that Joan had grown to love wearing dresses, that she hated being dirty, and
that she just loves to have her hair set.
84
Money concluded that his case
demonstrated that gender dimorphic patterns of rearing have an extraordi-
nary inuence on shaping a childs psychosexual dierentiation and the ulti-
mate outcome of a female or male gender identity. In a particularly enthusias-
tic moment, he wrote: To use the Pygmalion allegory, one may begin with
the same clay and fashion a god or a goddess.
85
Moneys account of psychosexual development rapidly gained favor as the
most progressive, most liberal, most up-to-date point of view around.
86
But
not everyone thought it made sense. In Milton Diamond, at the time a
young Ph.D., decided to take on Money and the Hampsons. He did so at the
suggestion and with the help of mentors who came from a rather dierent
tradition in the eld of psychology.
87
Diamonds advisers proposed a newpara-
digm for understanding the development of sexual behaviors: hormones, not
environment, they argued, were the decisive factor.
88
Early in development,
these chemical messengers acted directly to organize the brain; hormones
produced at puberty could activate the hormonally organized brain to pro-
duce sex-specic behaviors such as mating and mothering.
89
Although these
theories were based on studies of rodents, Diamond drew heavily on them to
attack Moneys work.
90
Diamond argued that Money and his colleagues, were essentially suggest-
ing that humans are sexually neutral at birth. He challenged their interpreta-
tions of their data, arguing that the very same data may not be inconsistent
with more classical notions of inherent sexuality at birth. Diamond agreed
that Money and his colleagues had shown that hermaphroditic individuals
. . . nd it possible to assume sexual roles opposite to their genetic sex, mor-
phological sex, etc. But he disagreed with their broader conclusions, ar-
guing, to assume that a sex role is exclusively or even mainly a very elaborate,
culturally fostered deception . . . and that it is not also reinforced by taboos
and potent defense mechanisms superimposed on a biological prepotency or pre-
natal organization and potentiation seems unjustied and from the present data
68 S i x r c . ni Br
Critical Stages
in Development Neutral Origin Biased Origin
Models of Psychosexual Development
Male B Female Male A Female
Conception
Sexual
Differentiation
Birth
Early
Critical Period
Puberty
Adulthood
Culturally and Biologically Imposed Limits to Development Within Which
Individually Preferred Behaviors are Contained.
rrcri .-: Models of psychosexual development. (Redrawn and interpreted from
Diamond .,t. Source: Alyce Santoro for the author)
unsubstantiated.
91
In other words, Diamond argued that even if Money and
his colleagues might be correctly interpreting intersexual development, their
work shed no light on what he called normals.
92
Diamond also pointed out that the John/Joan case was the sole example of
normal prenatal hormone exposure being overcome by rearing. In opposi-
tion to the Money and Hampson theory of gender neutrality molded by envi-
ronment into gender identity,
93
Diamond posed his own model of psy-
chosexual predisposition. He suggested that male and female embryos each
begin with partially overlapping but relatively broad potential for psychosex-
ual development. As both pre- and postnatal development proceeds, however,
there appear limits and restrictions in the formof culturally and biologically
acceptable sexual outlets within the total capability
94
(gure .-).
Only one other scholar dared to challenge Money.
95
In .,,- Dr. Bernard
Zuger, a practicing psychiatrist, found several clinical case studies in which
adolescent or adult intersexuals rejected their sex of rearing and insisted on
changing sex. These individuals seemed to be listening to some inner voice
O f G e n d e r a n d G e n i t a l s 69
that said that everyone in authority surrounding h/her was wrong. Doctors
and parents might have insisted that they were female, removed their testes,
injected them with estrogen, and surgically provided them with a vagina, but
still, they knew they were really males. Zuger concluded: The data from her-
maphrodites purporting to show that sex of rearing overrides contradictions
of chromosomes, gonads, hormones, internal and external genitalia in gender
role determination are found unsupportable on methodological and clinical
grounds. Conclusions drawn fromthe data as to the adoption of such assigned
gender role and the psychological hazard of changing it after very early child-
hood are shown not to be in agreement with other similar data found in the lit-
erature.
96
Money was furious. When Zugers paper appeared, he published a rebuttal
in the journal Psychosomatic Medicine, fuming, What really worries me, even
terries me, about Dr. Zugers paper, however, is more than a matter of theory
alone . . . it will be used by inexperienced and/or dogmatic physicians and
surgeons as a justication to impose an erroneous sex reassignment on a child
. . . omitting a psychological evaluation as irrelevantto the ultimate ruina-
tion of the patients life.
97
In his book with Anke Ehrhardt, Money
lashed out again: it thus appears that the prejudices of physicians skewtodays
hermaphroditic sex reassignment statistics in favor of change from girl to boy,
and in male rather than female hermaphrodites. It would not be necessary to
belabor this point except that some writers still do not understand it.
98
But Diamond pursued Money with a determination worthy of Inspector
Javert in Les Mise rables. Throughout the s and s he published at least ve
more papers contesting Moneys views. In a publication, he recounted
how psychology and womens studies texts had taken up John/Joan to sup-
port the contention that sex roles and sexual identity are basically learned.
Even Time magazine was propagating Moneys social constructionist doctrine.
But Diamond reiterated his viewthat nature sets limits to sexual identity and
partner preference and that it is within these limits that social forces interact
and gender roles are formulated, a biosocial-interaction theory.
99
(Note that
by the terms of the debate had shifted. Diamond now spoke of sexual
rather than gender identity, and a new term, partner preference, slipped in. I will
return to partner preferencethe origins of homosexualitylater.)
Diamond did not write this article just to gripe. He had big news. In
the BBC produced a TV documentary on the John/Joan case. At rst the
producers planned to feature Money and his views while using Diamond for
an oppositional backdrop. But the BBCreporters had found that by Joan,
then thirteen years old, was not well adjusted. She walked like a boy, felt that
boys had better lives, wanted to be a mechanic, and peed standing up. The
70 S i x r c . ni Br
psychiatrists then caring for the child thought she was having considerable
diculty in adjusting as a female and suspected she would not succeed in
remaining one. When the journalists told Money of these ndings, he refused
to talk further with them, and they broadcast the psychiatrists ndings of
Johns discontent without additional input from Money. Diamond learned of
all this from the BBC production team, but the lm did not air in the United
States. In an attempt to bring the facts to light in North America, Diamond,
in .,-, published a secondhand account of the documentary in the hopes of
discrediting Moneys sex/gender theory once and for all.
100
The paper did not make the splash Diamond had wanted. But he did not
give up. He started advertising in the American Psychiatric Association Journal,
asking the psychiatrists who had taken over John/Joans case to contact him
so that they could get the truth out in the open. But Johns psychiatrist, Keith
Sigmundson, who said he was shit-scared of John Money . . . I didnt know
what he would do to my career,
101
let years go by before he nally responded
and told Diamond what no other professionals had known: in .,-- Joan had
had her breasts removed, later had a penis reconstructed, and was married
and living with a woman and serving as her childrens father. Finally, Diamond
and Sigmundsen made front-page news when they published the update on
John/Joan, whom they now referred to as Joan/John.
102
Diamond and Sigmundson used the failure of Johns sex reassignment to
dispute two basic ideas: that individuals are psychosexually neutral at birth,
and that healthy psychosexual development is intimately related to the appear-
ance of the genitals. Using the compelling details of the updated story, in
which John/Joan/Johns mother now recounted his/her consistent rejection
of and rebellion against attempts to socialize him as a girl, Diamond argued
that far frombeing sexually neutral, the brain was in fact prenatally gendered.
The evidence seems overwhelming, he wrote, that normal humans are not
psychosexually neutral at birth but are, in keeping with their mammalian her-
itage, predisposed and biased to interact with environmental, familial and
social forces in either a male or a female mode.
103
Since the Diamond/Sigmundson expose, similar reports of rejection of
sex reassignments and of the successful rearing as males of children born with
malformed penises have received wide attention.
104
Diamond and a fewothers
have gained a foothold (although some still harbor doubts)
105
in calling for
newtreatment paradigmsabove all, postponing immediate and irreversible
surgery and providing counseling instead. With this management, Dia-
mond reasons, a males predisposition to act as a boy and his actual behavior
will be reinforced in daily interactions and on all sexual levels and his fertility
will be preserved.
106
O f G e n d e r a n d G e n i t a l s 71
The debate, however, is not over. In .,,- a group of Canadian psychiatrists
and psychologists published a follow-up of another case of sex reassignment
following ablatio penis (as accidental loss of the penis is so delicately called in
the medical literature). This child was reassigned at seven months (much ear-
lier than John/Joan, who was almost two years old when reassigned). In .,,-
the unnamed patient was twenty-six years old and living as a woman. She had
had love aairs with men, but had left her most recent boyfriend and nowlives
as a lesbian. She works in a blue-collar job practiced almost exclusively by
men. The authors note a strong history of behavioral masculinity during
childhood and a predominance of sexual attraction to females in fantasy. Yet
they do not argue that the sex assignment was entirely unsuccessful. Rather,
they insist that gender identity in this case was successfully changed by rearing,
even if gender role and sexual orientation were not. Perhaps, they conclude,
gender role and sexual orientation are more strongly inuenced by biologic
factors than is gender identity formation.
107
Their theories have sparked intense debate. Some sexologists, for exam-
ple, argue strongly that this paper by Susan Bradley and her colleagues actually
provides evidence for rather than against Diamonds position. And the conver-
sations have become even more nuanced as adult intersexuals have begun to
contribute their viewpoints. Not incidentally, they also suggest more complex
interpretations of the case studies than oered by academics or practicing
physicians.
108
Even John Money, who has refused to discuss the case, has
adopted a more intricate position. In a comment on another case of ablatio
penis, in which a dog attacked a child, he concedes that with both early and
late sex reassignment, the long term outcome is less than perfect. He ac-
knowledges that boys reassigned as girls often become lesbian, something he
views as a negative because of the associated social stigma. Without ever citing
Diamond or alluding to the debate, he concedes: There is, as yet, no unani-
mously endorsed set of guidelines for the treatment of genital trauma and
mutilation in infancy, and no provision for a statistical depository of out-
come data.
109
rirrrc ni.irsix.rr.:
. ni.r.n r.irsix.r rs . s.r.rcn. r.irsix.r!
A specter is haunting medicinethe specter of homosexuality. What seems
to be a recent focus on the connection between gender and sexual orientation
only makes more explicit concerns that have long motivated scientic discus-
sions of gender and intersexuality. It is impossible to understand the continu-
ing arguments over the treatment of intersexuals without putting themin the
historical context of highly charged debates over homosexuality. In the .,-s,
72 S i x r c . ni Br
as one historian writes, The media and government propaganda associated
homosexuals and other sex psychopaths with communists as the most dan-
gerous nonconformistsinvisible enemies who could live next door and who
threatened the security and safety of children, women, the family, and the
nation.
110
Joseph McCarthy and Richard Nixon saw homosexual Commu-
nists under every pumpkin leaf. When doctors chose to assign a denitive sex
to an ambiguously sexed child, then, it was not enough that the child become
psychologically male or female. For the treatment to count as successful, the
child had to become heterosexual. The Hampsons, who understood homosex-
uality as a psychopathology, a disorder of psychologic sex, stressed that
properly treated intersex children posed no threat of homosexuality.
111
They
advised medical practitioners that parents of intersexual children need to be
told that their child is not destined to grow up with abnormal and perverse
desires, for they get hermaphroditism and homosexuality hopelessly con-
fused.
112
One can hardly blame the parents for feeling confused. If intersexuality
blurred the distinction between male and female, then it followed that it
blurred the line dividing hetero- from homosexual. Might one, in the course
of treating an intersexual, end up creating a homosexual? It all came down to
how you dened sex. Consider an AIS child born with an X and a Y chromo-
some in each cell, testes and ambiguous but primarily female-appearing ex-
ternal genitalia. Because her cells are insensitive to the testosterone her testes
produce, she will be raised as a girl. At puberty her testes will make estrogen,
which will transform her body into that of a young woman. She falls in love
with a young man. She still has testes and an XY chromosome composition.
Is she homosexual or heterosexual?
Money and his followers would say she is blessedly heterosexual. Moneys
logic would be that this person, raised as a female, has a female gender iden-
tity.
113
In the complex trek fromanatomical sex to social gender, her male sex
chromosomes and gonads have been ruled unimportant because her hormonal
and assigned sex are female. As long as she is attracted to men, she is safely
heterosexual. We have chosen, medically and culturally, to accept this kind of
person as a straight woman, a denition she probably accepts as well.
114
Money and his collaborators developed their treatment programs for in-
tersexuality in the .,-s, when homosexuality was dened as a mental pa-
thology. Even so, Money himself is quite clear that the designation homosex-
ual is a cultural choice, not a natural fact. In discussing matched pairs of
hermaphrodites, some raised as girls and others as boys, he and Ehrhardt
write that such cases represent what is, to all intents and purposes, experi-
O f G e n d e r a n d G e n i t a l s 73
mentally planned and iatrogenically induced homosexuality. But homosexuality
in these cases must be qualied as homosexuality on the criterion of genetic sex, gonadal
sex, or fetal hormonal sex. Post surgically, it is no longer homosexuality on the
criterion of the external sex organs nor of the sex of replacement hormonal
puberty.
115
More recently, the gay liberation movement has inspired a change in views
that has helped medical practitioners see, to some extent, that their theories
are compatible with a more tolerant view of sexual orientation. Diamond,
who in .,t spoke of eeminacy and other sexual deviations, today writes
that it is our understanding of natural diversity that a wide oering of sex
types and associated origins should be anticipated. Certainly, he contin-
ues, the full gamut of heterosexual, homosexual, bisexual and even celibate
options . . . must be oered and candidly discussed.
116
Diamond continues
to argue that nature is the arbiter of sexuality, but now, he believes, nature
permits more than two normal types of sexuality. Today, he (and others) read
from nature a story of diversity. Of course, nature has not changed since the
.,-s. Rather, we have changed our scientic narratives to conform to our
cultural transformations.
s.rc six: .ni r.irsix.r .s ..ris ixrirri.
Moneys prescriptions for managing intersexuality paint him, and those who
agree with him, into an ideological corner. On the one hand, they believe that
intersexuals inhabit bodies whose sexual development has gone awry. On the
other hand, they argue that sexual development is so malleable that if one
starts with a young enough child, bodies and sexual identities can be changed
almost at will. But if bodily sex is so malleable, why bother maintaining the
concept?
117
Scientists struggling with this dilemma focus on intersexuals not only as
patients in need of medical attention, but also as a kind of natural experiment.
In particular, since the .,,-s, intersexuals have been central to the scientic
search for hormonal causes of behavioral dierences between the sexes. De-
liberate manipulations of hormones during development, performed with im-
punity on rats and monkeys, cannot be done on humans. But when nature
provides us with an experiment, it seems natural enough to study her oering.
Building upon extensive animal research (see chapter -) showing that go-
nodal hormones inuence behavioral development, investigators have used
intersexuals to examine three widely believed in sex dierences:
118
dier-
ences in sexual desire,
119
dierences in play in children, and dierences in
cognition, especially spatial abilities.
120
Analyzing this body of work shows
74 S i x r c . ni Br
how intersexuals, seen as deviations from the norm who need to be xed
in order to preserve a two-gender system, are also studied to prove how nat-
ural the system is to begin with.
Consider, for example, the attempts of modern psychologists to under-
stand the biological origins of lesbianism by studying female intersexuality
caused by hyperactive adrenal glands (CAH). CAHgirls are born with mascu-
linized genitalia because their overactive adrenal glands have, during fetal de-
velopment, produced large amounts of masculinizing hormone (androgen).
When discovered at birth, the overproduction of androgen is stopped by treat-
ment with cortisone and the genitals are feminized by surgery.
Even though to date there is no direct evidence to show that, in human
embryos, hormones aect brain and genital development during the same
time period,
121
scientists wondered if the excess prenatal androgen also
aected brain development. If the fetal brain were masculinized, permanently
altered by exposure to testosterone, would that cause CAH girls to have
more masculine interests and sexual desires? The question itself suggests a
particular theory of the lesbian as fallen woman. As the psychoanalysts Maggie
Magee and Diana Miller write, A woman who makes her emotional and inti-
mate life with another woman is seen as having fallen from the path of true
feminine development, expressing masculine not feminine identication and
desires.
122
Applying this concept to CAH girls seemed to make sense. Their
extra androgen production had caused them to fall from the path of true
female development. Studying CAH girls, then, might provide support for
the hypothesis that hormones, gone awry, lie at the heart of homosexual devel-
opment.
123
From .,t- to the present, approximately a dozen (the number continues
to grow) studies have looked for evidence of unusual masculinity in CAHgirls.
Were they more aggressive and active as children? Did they prefer boys toys?
Were they less interested in play rehearsal of mothering and, the ultimate
question, did they become lesbians or harbor homosexual thoughts and de-
sires?
124
In the gender system that frames this research, girls who like boys
toys, climb trees, dont like dolls, and think about having careers are also
likely to be prone to homosexuality. Sexual attraction to women is understood
to be merely a male-typical form of object choice, no dierent in principle
from liking football or erector sets. Girls with masculine interests, then, may
reect an entire suite of behaviors, of which adult homosexuality is but a post-
pubertal example.
125
Recently Magee and Miller analyzed ten studies of CAH girls and women.
Although Money and colleagues originally reported that CAHgirls were more
active than controls (higher energy expenditure, more aggressive, more
O f G e n d e r a n d G e n i t a l s 75
rough-and-tumble play),
126
more recent work, Miller and Magee conclude,
does not bear them out.
127
Furthermore, none of the studies found increased
dominance assertion in CAH girls.
128
A few publications report that CAH
girls are less interested than control girls (often unaected siblings) in doll
play and other forms of rehearsal for motherhood. Inexplicably, however,
one research group found that CAH girls spent more time playing with and
caring for their pets, while other researchers found that CAHpatients did not
wish to have their own children and more often preferred the idea of a career
to staying at home.
129
All in all, the results provide little support for a role for
prenatal hormones in the production of gender dierences.
Magee and Miller nd special fault with the ten studies of lesbianism in
CAH women. These, they point out, contain no common concept of female
homosexuality. Denitions range from lesbian identity, to homosexual rela-
tionships, to homosexual experience, to same-sex fantasies and dreams.
130
Although several studies report increases in homosexual thoughts or fantasies,
none found exclusively homosexual CAHfemales. One of the research groups
concluded that prenatal hormone eects do not determine the sexual
orientation of an individual,
131
others cling to the idea that early exposure
to androgens may have a masculinizing inuence on sexual orientation in
women.
132
Thus, a critical look at the studies of masculine development in CAH girls
reveals a weak, problem-ridden literature. Why, then, do such studies con-
tinue to appear? I believe these highly skilled, well-trained scientists,
133
re-
turn again and again to drink from the well of intersexuality because they are
so deeply immersed in their own theory of gender that other ways of collect-
ing and interpreting data become impossible to see. They are sh who swim
beautifully in their own oceans but cannot conceptualize walking on solid
ground.
134
Wr ap-Up: Re adi ng Nat ur e I s a Soc i oc ul t ur al Ac t
All choices, whether to treat with chemicals, perform surgeries, or let geni-
tally mixed bodies alone, have consequences beyond the immediate medical
realm. What might the phrase social construction mean in the material
world of bodies with diering genitals and diering behavior patterns? The
feminist philosopher Judith Butler suggests that bodies . . . only live within
the productive constraints of certain highly gendered regulatory schemas.
135
The medical approaches to intersexual bodies provide a literal example. Bod-
ies in the normal range are culturally intelligible as males or females, but
the rules for living as male or female are strict.
136
No oversized clits or under-
76 S i x r c . ni Br
sized penises allowed. No masculine women or eeminate men need apply.
Currently, such bodies are, as Butler writes, unthinkable, abject, unliv-
able.
137
By their very existence they call into question our system of gender.
Surgeons, psychologists, and endocrinologists, through their surgical skills,
try to make good facsimiles of culturally intelligible bodies. If we choose to
eliminate mixed-genital births through prenatal treatments (both those cur-
rently available and those that may become available in the future), we are also
choosing to go with our current systemof cultural intelligibility. If we choose,
over a period of time, to let mixed-gender bodies and altered patterns of
gender-related behavior become visible, we will have, willy-nilly, chosen to
change the rules of cultural intelligibility.
The dialectic of medical argument is to be read neither as evil technologi-
cal conspiracy nor as story of sexual open-mindedness illumined by the light
of modern scientic knowledge. Like the hermaphrodite h/herself, it is nei-
ther and both. Knowledge about the embryology and endocrinology of sexual
development, gained during the nineteenth and twentieth centuries, enables
us to understand that human males and females all begin life with the same
structures; complete maleness and complete femaleness represent the ex-
treme ends of a spectrum of possible body types. That these extreme ends are
the most frequent has lent credence to the idea that they are not only natural
(that is, produced by nature) but normal (that is, they represent both a statisti-
cal and a social ideal). Knowledge of biological variation, however, allows us
to conceptualize the less frequent middle spaces as natural, although statisti-
cally unusual.
Paradoxically, theories of medical treatment of intersexuality undermine
beliefs about the biological inevitability of contemporary sex roles. Theorists
such as Money suggest that under certain circumstances the body is irrelevant
for the creation of conventional masculinity and femininity. Chromosomes
emerge as the least important factor, the internal organsincluding the go-
nadsas the next least important. The external genitalia and secondary sex
characteristics obtain status for their ability to visually signal to all concerned
that one should behave in certain gender-appropriate ways. In this view the
society in which the child is reared, not mysterious inner bodily signals, de-
cides which behaviors are appropriate for males and which for females.
Real-life medical practitioners, however, concerned with convincing par-
ents, grandparents, and nosy neighbors about gender choices made for inter-
sex infants, develop a language that reinforces the idea that lurking inside the
mixed-sex child is a real male or female body. Thus they also encourage the
idea that children are actually born with gender and contradict the idea that
gender is a cultural construction. The same contradiction emerges when psy-
O f G e n d e r a n d G e n i t a l s 77
chologists appeal to prenatal hormones to explain supposedly higher frequen-
cies of lesbianism and other desires deemed inappropriate for a psychologi-
cally healthy female.
Within these contradictory practices and views there is room for maneu-
ver. Scientic and medical understandings of multiple human sexes bring with
them both the means to disrupt and the tools to reinforce dominant beliefs
about sex and gender. Sometimes feminist analyses of science and technology
present these enterprises as monolithic behemoths against which all resistance
is powerless. Feminist accounts of reproductive technology have been particu-
larly susceptible to this view, but recently the philosopher Jana Sawicki has
provided a more empowering analysis. She writes: although new reproduc-
tive technologies can sustain the status quo for existing power relations,
technology also oers new possibilities for disruption and resistance.
138
Not
only is this also the case for the medical management of intersexuality, I sug-
gest it is always the case. Feminists must become comfortable enough with
technology to ferret out the points of resistance.
Our theories of sex and gender are knitted into the medical management
of intersexuality. Whether a child should be raised as a boy or girl, and sub-
jected to surgical alterations and various hormonal regimes, depends on what
we think about a variety of matters. How important is penis size? What forms
of heterosexual lovemaking are normal? Is it more important to have a sex-
ually sensitive clitoriseven if larger and more penile than the statistical
normthan it is to have a clitoris that visually resembles the common type?
The web of knowledge is intricate and the threads always linked together.
Thus we derive theories of sex and gender (at least those that claim to be
scientic or nature-based) in part from studying intersexual children
brought into the management system. When needed we can, as well, appeal
to animal studies, although those too are produced within a social system of
sex and gender beliefs (see chapter ).
This does not mean, however, that we are forever stuckor blessed, de-
pending upon your point of viewwith our current account of gender. Gen-
der systems change. As they transform, they produce dierent accounts of
nature. Now, at the dawn of a newcentury, it is possible to witness such change
in the making. We are moving from an era of sexual dimorphism to one of
variety beyond the number two. We inhabit a moment in history when we
have the theoretical understanding and practical power to ask a question un-
heard of before in our culture: Should there be only two sexes?