This article originally appeared in T&S Issue 41, Summer 2000.
The first pronouncement made on the birth of a baby is usually ‘It’s a girl’ or ‘it’s a boy’. What happens when a baby is not easily classifiable into one of these either/or categories? Stevi Jackson reviews two recent books on intersexuality and discusses their implications for feminism.
There has been a great deal of discussion in recent years about the bending, blending, blurring and transgression of gender boundaries. The old-style transsexual who simply wanted to be a member of ‘the other sex’ has given way to a new style ‘gender outlaw’ who lays claim to a liminal, transgendered status (see Debbie Cameron in this issue). Much is made of the supposedly destabilising potential of such gender transgression. Far less is heard about those who are born neither clearly female nor clearly male but who are quite literally forced, without their consent and often with the aid of invasive and damaging surgical techniques, into one category or the other. These are the intersexed or, as they are increasingly calling themselves, intersexuals. This hidden population has, in the last few years, begun to organise politically against a medical establishment that mutilates their bodies and against a social order that makes living as a hermaphrodite impossible. Two recent books have taken up their cause and put the issue firmly back on the feminist agenda: Suzanne Kessler’s Lessons from the Intersexed and Anne Fausto-Sterling’s Sexing the Body.
Sex differences and intersex
Both Susanne Kessler and Anne Fausto-Sterling start from the assumption that biological sex differences cannot themselves be taken for granted, but they approach the problem from somewhat different angles. Anne Fausto-Sterling is a feminist biologist who has, for many years, been challenging the scientific orthodoxy on sex and gender, notably in Myths of Gender. She can usually be counted on to expose the faulty methodology underlying the latest scientific fads (such as ideas about ‘gay brains’ and ‘gay genes’). One point she has consistently made is that research of this kind is inevitably biased by scientists’ presuppositions. In particular, it is assumed in advance that there are two distinct groups, female and male (or gay/lesbian and straight) and that differences between them can be found in everything from hormones, through brain function to particular aptitudes. Since scientists set out to look for differences rather than similarities, and since they design their studies in terms of dichotomies rather than continua, they simply find what they were looking for — which then further confirms the ‘rightness’ of the presuppositions they started with.
This argument also underpins Sexing the Body — some of which deals simply with research on sex differences per se — although it is the focus on intersex, the main subject of the book, which I will discuss here. Fausto-Sterling shows how scientific assumptions about the ‘naturalness’ and normality of sexual duality underpin the medical management of those whose bodies contradict these assumptions: these bodies are literally forced to fit in with what is deemed ‘natural’. She charts the history of scientific ideas about intersex and provides copious (and sometimes gruesome) details on modern medical interventions. For anyone interested in such details, Sexing the Body is a useful source of information. Where Fausto-Sterling’s analysis is less convincing, however, is in her discussion of the consequences of intersex for the ways in which we theorise sex and gender. Indeed her conceptualisation of sex, gender and sexuality is sometimes extremely blurry and confusing, especially in her first chapter.
Lessons from the Intersexed is a shorter and much more satisfying book. It is focused more exclusively on the social construction of intersex and is based upon interviews with the doctors who diagnose and treat intersexed children, parents of intersexed children and adult intersexual activists. Unlike Anne-Fausto-Sterling, Suzanne Kessler underpins her argument with a consistent and explicit theory of gender. This derives from her earlier collaboration with Wendy McKenna. In Gender: An Ethnomethodological Approach, published in 1978, Kessler and McKenna developed one of the earliest critiques of the sex-gender distinction, arguing that there is no sex, only socially constructed gender. Since ethnomethodology is not now fashionable, and may well be unfamiliar to many T&S readers, I will briefly explain its basic premises.
Ethnomethodologists investigate how social order is made possible at the level of everyday social practices, how a shared sense of social reality is daily constructed and reconstructed through the interpretative work that members of society routinely engage in. They look closely at the unquestioned assumptions underpinning this everyday practical reasoning, revealing that they are social products rather than part of some natural order. One such assumption, of course, is that the world is ‘naturally’ divided into two sexes or genders. Ethnomethodologists see gender as a practical accomplishment rather than a natural fact. It is the product of gendered performances and the assumptions we bring to reading those performances, thus attributing gender to others. This may sound rather similar to some later postmodern feminist arguments, such as those of Judith Butler. There are some similarities, but ethnomethodology is far more sociologically grounded, focused far more concretely on the mundane, everyday social contexts and practices that are largely absent from the work of Butler and her ilk.
Kessler and McKenna stress the primacy of gender attribution over all other aspects of gender: it is only because we make a gender distinction in the first place that we are able to perceive and talk about differences between women and men. Since the existence of a gendered social reality depends upon the distinction of gender, we cannot get rid of gender inequalities without ridding ourselves of gender itself. Kessler and McKenna use the term ‘gender’ even when referring to differences assumed to be biological. Hence they refer to ‘gender’ chromosomes and ‘gender hormones’ not because they don’t understand the sex-gender distinction (see Debbie Cameron in this issue), but because they wish to challenge it. They refuse to accept that gender is founded on a fixed pre-social reality. They suggest that the recognition of all gender differences (including so-called ‘biological sex’) is always a social act. They develop the idea of ‘cultural genitals’ — the genitals someone is assumed to have or ‘ought’ to have (a concept originally suggested by the founder of this perspective, Harold Garfinkel). It is these cultural genitals, rather than biological genitals, that serve as insignia of femaleness or maleness in everyday life.
This, then, is the perspective that informs Kessler’s analysis of intersexuality. Despite her insistence on the term ‘gender’, she continues to use the words ‘intersex’ or ‘intersexed’ (to describe the condition) and intersexuals (to describe those with the condition), apparently because this is the terminology currently used. There is, currently, no widely accepted alternative vocabulary other than that deriving from the older ‘hermaphrodite’, a word which denoted someone who was perceived as being a combination of male and female. The term ‘intersex’ does at least have the virtue of differentiating intersexuals from transsexual and transgendered people, those who choose to change or modify their gender. Some of those embracing the supposed radicalism of being a ‘gender outlaw’ would rather we saw intersex as part of the same phenomenon — this, for instance, is the position taken by Pat Califia (the well-known S/M activist) in her recent book Sex Changes. From a feminist perspective I would prefer to maintain the distinction. For the record, I think that an intersexed woman who is made female in infancy and has lived her whole life as female is a fully social woman in a way that a transsexual or transgendered ‘woman’ can never be.
I have no idea whether Suzanne Kessler would agree with the point of view I have just outlined, but I find the direction of her argument compelling. She makes it clear that the medical practice of ‘correcting’ intersex in infancy is shaped by, and serves to reinforce, the taken-for-granted assumptions underpinning our gendered social reality. Thus supporting intersexual activists campaigns against early and non-consensual ‘correction’ is not only a human rights issue, but also furthers the feminist goal of eradicating gender — or at least reducing its significance. She makes this argument, however, from a perspective that differs from my own, materialist feminist, position. Whereas Kessler, as an ethnomethodologist, asks how gender is sustained as a meaningful social distinction, a more structural materialist position asks why it exists at all — and answers that why in terms of patriarchal, hierarchical social arrangements. Both, however, are social explanations and there may be room for the insights each offers — although I would always want to retain an emphasis on the power structure underpinning gender as something fundamental to a radical feminist perspective.
Intersex as a feminist issue
It is perhaps strange that feminists have so easily forgotten the intersexed. When, in the 1970s, we began to argue for a concept of socially constructed gender distinct from biological sex, studies of the intersexed were widely cited to demonstrate that gender and biological sex did not necessarily coincide (see, for example, Ann Oakley’s Sex, Gender and Society). While biological sex was often taken for granted as a natural fact, even at this stage it was noted that it was not strictly dichotomous, that while most individuals fell into the normal distribution of male and female, a few had a mix of male and female genetic and hormonal markers. Now that it is more widely acknowledged that biological ‘sex’ is as much a social construction as gender, it is time we looked again at intersex.
There can be no more compelling evidence for the social origins of gender than the management of intersex. The ways in which the medical profession decide which category an intersexed child should be placed in reveals much about our taken for granted assumptions about the interrelationship between sex, gender and sexuality and dramatises the fact that the assignment of sex is always a social act. But this is not the only reason for considering intersex to be a feminist issue. The violence done to the bodies of very young children in the name of making them ‘normal’ can be seen as involving both genital mutilation and sexual abuse. Feminist perspectives obviously have something to offer here, but feminists may also have something to learn from the experience of the intersexed.
These two issues — social construction of sex and gender and abuse of children’s bodies — intersect. The medical management of intersex is evidence of the lengths our society, through its socially appointed medical experts, is willing to go to shore up ‘normality’ of gender divide. Moreover, the forcible gendering of intersexed bodies serves to conceal those whose bodies might challenge our taken-for-granted assumption that everyone is naturally one or the other: their difference from gendered norms is made to disappear with the aid of the surgeon’s scalpel and the endocrinologist’s hormones. And because of the secrecy that surrounds this disappearing of hermaphrodite bodies, most of us don’t know they ever existed, exacerbating the isolation felt by intersexuals themselves. Hermaphrodites With Attitude, the newsletter of the Intersex Society of North America (ISNA) called for breaking the vicious circle in which shame about variant genitals ‘produces silence, silence condones surgery and surgery produces more shame (which produces more silence)’ (Quoted by Suzanne Kessler pp. 79-80.)
Making intersex (in)visible
So how common is it? Anne Fausto-Sterling comes up with a figure of 1.7% of all births, based on a list of common intersexed conditions for which frequency data is available. This does not include all intersexed conditions, not even all relatively common ones; conversely not all of those she includes necessarily produce obvious gender ambiguities at birth — sometimes incongruous gender markers only become evident at puberty. Some of those who are technically intersexed never become statistics at all; it is possible for a woman who has never been suspected of being anything else to have ‘male’ chromosomes. She may live out her life without ever knowing she is technically a genetic male — unless she is an athlete, when she might suddenly discover that she does not qualify as a woman. According to the evidence cited by Mariah Burton Nelson (see T&S 29/30) about twelve women athletes a year are found to have a Y chromosome — but most agree to retire gracefully and quietly without making their condition publicly known.
Intersex, then, is probably far more common than most of us think. Fausto-Sterling compares it with Albinism, which occurs in only 1 in 20,000 births — yet most of us know about it. Intersex, however, remains invisible and almost unheard of. While conditions which produce obvious genital variance at birth account for only a small proportion of the total intersexed population, they still occur with measurable frequency and often enough for those who work in midwifery and obstetrics to encounter several cases during their careers. Recently a midwife told me that she had delivered two babies with clear gender ambiguity and that most maternity units could expect to see at least one such birth each year.
The existence of hermaphrodites has been recorded throughout Western history, from the time of early Greek and Roman civilization onwards. According to Anne Fausto-Sterling, hermaphrodites have always been regarded as anomalous, but have been treated with varying degrees of tolerance or intolerance at different historical periods and in different countries. Prior to the rise of modern medical management, their fate was largely a legal matter, but in the 19th century, science and medicine began to exert more influence. It was then, Fausto-Sterling points out, that hermaphrodites began to be made to disappear. A distinction emerged between the ‘true’ hermaphrodite and the spurious or pseudo-hermaphrodite. By the late 19th century what defined the ‘true’ hermaphrodite was having the gonads of both sexes — i.e. one ovary and one testis or hybrid ovo-testes. Those who had testes, a vagina and breasts or those with ovaries and a penis were pseudo-hermaphrodites. This distinction is still with us, with the addition of chromosomal markers. So someone with a vagina, clitoris and breasts but XY chromosomes is a male pseudo-hermaphrodite and someone with XX chromosomes and a penis and typically male body shape is a female pseudo-hermaphrodite. ‘True’ hermaphroditism on this definition is very rare, occurring about once in 100,000 births.
With twentieth century advances in surgery and endocrinology, it became increasingly possible to make hermaphrodites disappear in a more fundamental way: to transform them physically so that they were placed firmly on one side or the other of the gender divide. The medical histories Fausto-Sterling cites from the 1920s and 1930s mostly concern adults and adolescents, who do not seem to have been coerced into transforming their bodies. Those who opted for medical intervention has a choice, not only about whether to undergo surgery, but about which direction they wanted to go in — and most chose maleness.
Now most intersexuals have no choice and most are made female. What changed was that, in the second half of the twentieth century, it became easier to locate intersexed individuals as birth and surgically ‘correct’ them in infancy and childhood. Intersex was constructed as a tragic error of nature, which doctors had a duty to put right. The decisions doctors now take on how to ‘put it right’, despite being ostensibly based on ideas about the child’s ‘true sex’, are in fact governed by what is technically feasible and by cultural assumptions about ‘acceptable’ gendered genitals. Hence a genetic female with reproductive potential will almost always be assigned as female even if her genitals look like those of a boy, but a genetic male without an ‘adequate’ penis may also be assigned to the female category — in part because surgery cannot effectively construct or enlarge penises and also because it is assumed that a secure male identity is unsustainable without a ‘proper’ penis. So girls are constructed from both genetic girls and genetic boys.
Current medical practice aims to keep this ‘problem’ invisible by ‘normalising’ disruptively gendered bodies as fast as possible with as few non-medical personnel as possible knowing about it. Fausto-Sterling describes how doctors react when a child with variant genitals is born in a Western hospital.
They declare a state of medical emergency… there is no time to waste in quiet reflection or open-ended consultations with the parents. 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. (p.45).
Kessler found, however, that decisions were not always taken this quickly; sometimes more extended testing is undertaken — especially if the child has a Y chromosome and a microphallus that looks like it may have the potential to become a penis. An extended period of gender ambiguity is, however, seen as problematic by medics and a situation that needs to be resolved as fast as possible.
Whether they come to a speedy decision or not, doctors are careful to avoid directly confronting parents with the notion that their child is intersexed. They are told that their child’s genitals are ambiguous, not its gender, that the genitals are poorly developed or unfinished, but that the doctors will discover the ‘true’ gender of the child, correct this ‘minor defect’ and all will be well. Obviously this medical fiction becomes more difficult to sustain if the doctors can’t make up their minds quickly — while the parents have to fend off friends and relatives wanting to know whether they have a boy or a girl. Parents then have to be persuaded to collude with maintaining the silence, to evade others’ questions (and are offered various strategies for achieving this). Thus, Kessler says, ‘parents are asked to side-step the question of the infant’s gender rather than admit that the gender is unknown, thereby collaborating in a web of white lies, ellipses and mystifications’ (p.22).
Rarely are parents given the opportunity for truly informed consent to any of the medical procedures, since they are generally prevented or dissuaded from seeking alternative perspectives. Kessler’s letters from and interviews with parents reveal that most, in any case, seem to accept the medical view without questioning it. This she sees as unsurprising: the doctors are perceived as the experts, no other perspectives are available to them and they want their children to look ‘normal’.
Parents are presented with a comprehensive treatment plan involving medication and surgery that is presented as imperative and non-negotiable. The medical view is the authoritative view and parents adopt it.
(Lessons from the Intersexed p. 97)
Challenging the orthodoxy
The sense of medical emergency and doctors’ evasiveness about gender ambiguity are based on certain presuppositions: that a secure gender identity must be established as early in life as possible; that to accomplish this, parents must have no doubt about the underlying sex of their infant; that the genitals must be made to match the gender assigned as soon as possible, followed by appropriate hormone treatment at puberty. Neither the child nor the parents should be given reason to question the gender assigned; they must accept that it is ‘real’ even if it does not conform to the usual biological markers.
These ideas derive from a theory of gender identity developed by John Money, and from his guidelines for medical practice. In particular Money argued that genitals were important not because they directly determined gender, but because they were fundamental to a child’s developing sense of herself or himself as a boy or a girl. This has, in the last few decades become the medical orthodoxy, so that the doctors interviewed by Kessler never considered any alternative possibilities or gave credence to any evidence that contradicted the efficacy of Money’s regime (see pp.14-16). Money does have a few critics within medicine, but these seem intent on reinforcing gender dualism by accusing Money of paying insufficient attention to the ‘true’ biological sex of children in making decisions on genital surgery. Anne Fausto-Sterling surveys this work and strangely seems to endorse it, without noticing the reactionary implications of the critique offered (see pp. 66-71). This is peculiar to say the least given that she also cites Kessler’s critique approvingly — and Kessler attacks Money from the opposite direction.
It is something of an irony — and one noted by Kessler — that Money’s work, which demonstrated the plasticity of gender and the primacy of social over biological factors in shaping it, serves the brutal enforcement of gender dimorphism. Indeed it is precisely the premise that the gender in which we are reared matters more than our underlying biological sex that justifies current medical practice. Kessler argues that earlier theorists of gender, herself included, were so impressed by his scientific ‘proof’ that gendered identities were socially constructed, that they failed to notice some ‘unexamined and deeply conservative assumptions embedded in Money’s argument.’ (p.7) These she outlines as follows:
Genitals are naturally dimorphic; there is nothing socially constructed about the two categories.
Those genitals that blur the dimorphism belonging to the occasional intersexed person can and should be successfully altered by surgery
Gender is necessarily dichotomous (even if socially constructed) because genitals are naturally dimorphic.
Dimorphic genitals are the essential markers of dichotomous gender.
Physicians and psychologists have legitimate authority to define the relationship between gender and genitals.
(Lessons from the Intersexed, p.7)
All of these could be said to boil down to one single assumption — that even if specific gendered identities are constructed, gender itself is somehow natural and inevitable. As Suzanne Kessler says, we need to ask why genitals are considered so important in and of themselves. We also need to ask why the gender division itself has to be sustained at all cost.
Radical intersexual activists are also beginning to ask some similar questions — why, for example, should surgery not be postponed until children are capable of choosing for themselves whether they want to undergo painful surgery and aftercare and why should everyone’s bodies be made to fit the narrow criteria of gendered normality? They are not suggesting that such children be made to live without a gender, but that a gender assignment could be made without surgical intervention, allowing for greater choice and flexibility later in life. Since the more radical of these activists are arguing for forms of social change that would make it possible to live with gender ambiguity, it is not surprising that they are not accorded much credibility by the medical profession. Doctors are more willing to enter into dialogue with those who confine themselves to asking for ‘improved’ forms of treatment. If medics were to take radical intersexuals seriously, they would have to face the possibility that their practices might not be in the interests of their patients, but might serve quite other interests. As Kessler puts it:
Accepting genital ambiguity as a natural option would require that physicians also acknowledge that genital ambiguity is ‘corrected’ not because it threatens the infant’s life, but because it threatens the infant’s culture. (p. 32)
When is a micropenis a ‘masculinised’ clitoris?
There is one obvious conclusion, as Kessler notes, that doctors fail to draw from their work with intersexed children: that gender is always a construction and could be otherwise. They see themselves as merely ‘correcting’ or ‘reconstructing’ genitals — never as actively constructing them. Yet they are engaged in the social construction of gender in a very literal sense, in that gender is being made by human intervention informed by cultural assumptions about what gender ought to be. Here infants’ genitals are surgically re-made in the image of cultural genitals — the genitals that doctors decide they ought to have. And what is culturally acceptable is defined in very specific ways, underpinned by gendered and profoundly heterosexist assumptions.
In the vast majority of cases the attribution of gender to a child at birth, although a social act, seems to happen without reflection or deliberation. As Kessler says, those delivering babies do not usually stand with a ruler in their hands measuring the genitals up before they pronounce judgement. But rulers become vitally important once it is decided that the genitals are ambiguous. What we are dealing with here are genitals that disrupt our normal criteria for deciding what male and female genitals are. There are two anatomical structures in question — one is an organ considered too big to be a clitoris or too small to be a penis, the other is something that can be perceived either as fused labia or as a scrotal sac. Such variance can’t simply be seen as just that, a variation on human possibilities, but must be redefined in terms of two mutually exclusive categories, female and male. Hence for example, a large clitoris and fused labia are read as masculinisation.
This is where rulers come in and this is where it becomes clear that genitals are only allowed to vary within small limits. To be medically acceptable a baby’s clitoris must be under 0.9cm in length and an infant penis (flaccid, but stretched) must be over 2.5cm in length. Both Kessler (on p. 43) and Fausto-Sterling (p. 59) represent this graphically, as markers on a ruler. There is, therefore, a range between 1cm and 2.4cm representing an organ that is unacceptable for either a boy or a girl. The fate of this organ which fails to measure up or down is usually surgical -as is also the case for those labelled clitorises that might technically measure up as penises: Kessler cites one medical study of clitoral reduction involving clitorises that had originally ranged up to 3.5cm in length.
So how are these decisions taken? One factor already mentioned is that genetic females with the potential to bear children will almost always be designated female. This is the case for example, with those suffering from congenital adrenal hyperplasia (CAH). CAH is one of the few intersexed conditions that may actually require medical intervention since some forms are associated with a potentially life-threatening inability to metabolise salt — though, of course, this does not necessitate genital surgery. Some CAH babies can have genitals that look much like those considered appropriate for a boy, but because their other medical problems are likely be discovered, they are reassigned as girls and consigned to the operating table.
We also need to consider what it takes to be defined as a boy: a big enough penis and the ability to pee standing up. A ‘proper’ penis not only has to be long enough and thick enough, it also has to have a urethra running through it and emerging at the tip of the glans. If the urethra emerges somewhere else — markedly off-centre, halfway along the penis or at its base, the condition is known as hypospadias. Whereas small size can only be altered, if at all, by hormone therapy, hypospadias is dealt with surgically — although severe hypostadias plus small penis usually equals female. Some micropenises will respond to testosterone treatment. This is usually only tried if the organ is considered not too severely undersized — and it takes time to see if it will work. If it doesn’t work, the micropenis becomes redefined as a large clitoris, the boy reassigned as a girl and, again, is consigned to the operating table.
If the micropenis grows, don’t assume that the boy — for boy he will now be — has a rosy future. In the first place, testosterone treatment simply hastens the penile growth that would normally happen in adolescence. Hence the boy might acquire a penis similar in size to those of his primary school classmates — but it will stay that size. As an adult man he will still have a little boy’s penis. Second, he hasn’t escaped the surgeon’s scalpel — remember he must also be able to pee standing up and the chances are that the micropenis is also hypospadic. It may require many bouts of surgery to construct a urethral opening in the right place for a proper male — sometimes as many as three operations in the first two years of life, with more later. The numbers of operations undergone by some boys runs into double figures; often further operations are needed to put right mistakes that have been made in earlier ones. A diagnosis of hypospadias is only made, of course, if it has been decided that the child is male. It should also be noted that hypospadias, with all its attendant problems, occurs in boys who are not otherwise considered intersexed. However, hypospadias itself is sometimes considered a form of intersex; it is certainly a form of genital variation and the efforts made to remedy it indicate that it is also considered a deviation from acceptable standards of maleness.
Because it is difficult to enlarge penises surgically, most intersexed children end up as girls. So what happens to them once that gender assignment is made? A word of warning — this is where is gets truly gruesome, so the squeamish may wish to skip the next section.
The first step in the surgical fix is to ‘do something’ about the clitoris. Why? Kessler’s reading of the medical literature reveals that a large clitoris is considered ‘disfiguring’, ‘deformed’, ‘offensive’, ‘offending’, ‘ungainly’. ‘unsightly’ and, above all ‘unfeminine’ or ‘masculine’. It therefore ‘requires’ or ‘demands’ ‘corrective surgery’, it ‘must’ be reduced; this is ‘necessary’ — apparently to produce proper psychological adjustment (see pp.35-38). The main reasons appear to be cosmetic, to make the baby look like a ‘proper little girl’ so that her parents will accept her as such and rear her as such. Such aesthetic judgements are very clearly based on value judgements, but the medical profession persistently disguises these as ‘objective’ clinical evaluations.
On the basis of this, drastic action is taken. Up until the 1960s the most popular remedy was simply to excise this offensive and offending organ altogether, to perform a clitoridectomy. When it began to dawn on the medical profession that the clitoris might have something to do with sexual pleasure and orgasmic potential, they tried other methods. Yet they still seemed to be more concerned about how the finished ‘corrected’ version looked rather than whether it was sexually functional. The two main techniques used are clitoral reduction and clitoral recession. As described by Anne Fausto-Sterling, in clitoral reduction ‘the surgeon cuts the shaft … and sews the glans plus preserved nerves back onto the stump’; in clitoral recession, ‘the surgeon hides the clitoral shaft under a fold of skin’ (the diagram shows how it is sutured into place) ‘so that only the glans remains visible’ (p. 61, with diagrams on pages 62 and 63). The initial operation is done as soon after birth as possible, but sometimes further operations are done in order to improve the ‘cosmetic effect’. More modern techniques do not necessarily preserve orgasmic function and many adult intersexuals report pain and or hypersensitivity in the clitoris or clitoral stump.
This is not the end of it. Many intersexed girls also have fused or otherwise unusual labia and either very small or non-existent vaginas. Vaginoplasty (the general term for enlarging, creating or modifying a vagina) is considered medically ‘necessary’ to produce a proper female. Doctors have differing views on when this operation is done: some favour early surgery in the hope that full femaleness will be established early and the child may forget about it; some favour leaving it until later given its possible complications. Almost all, however, prefer it to be accomplished before puberty and there seems to be a definite preference for getting it over with before the child is old enough to understand what is being done to her or why. The ‘why’, of course, is to produce a vagina large enough to accommodate the average erect adult penis.
One surgeon, used to dealing with reconstructive surgery on adult women with vaginal cancers, told Suzanne Kessler that the construction of a vagina in intersexed children is simple by comparison:
So you create a vagina which is no big deal. You create a cavity, line it with some skin which you can take from the buttocks or the thigh and you have a functional vagina. (Lessons from the Intersexed p. 60)
No big deal? This is an operation, performed on adult transsexuals as well as child intersexuals, which has a very high failure and complication rate. There is a good chance of post-operative and sometimes continuing infection and growth of painful scar tissue. Other complications can include hair growth at the entrance to the vagina and urinary tract problems. The most common problem, and one affecting almost all those who have the operation in infancy, is stenosis, a narrowing of the vaginal canal ‘requiring’ (i.e. according the surgeons) further operations. The new or enlarged vagina has to be kept open with the daily use of a dilator and often, despite all efforts, closes up again — resulting in repeated surgery, more infection, more scarring and so on. For example, Anne Fausto-Sterling reports one review of vaginoplasties on 28 girls carried out at John Hopkins University Hospital between 1970 and 1990. 22 of these girls required further surgery; of these, 17 had already had two surgeries and five had already had three. Kessler cites a number of studies indicating a similar pattern. The human suffering behind such statistics must be immense.
Even adult transsexuals sometimes give up in the face of the problems this operation causes — and they made a choice to begin with and were usually fully informed about the dangers and pain involved. Children are not — they must simply endure butchery of their genitals without even understanding why it is happening. The evidence provided by both Suzanne Kessler and Anne Fausto-Sterling is that children suffer genital mutilation combined with follow-up treatment that is tantamount to sexual abuse.
At the very least intersexed children often undergo repeated medical procedures on and examinations of their genitals. Adult intersexuals often recall that repeated examinations, often conducted in front of a retinue of medical students, were a constant cause of embarrassment and humiliation in their childhoods. Even simple medical examinations can be abusive. One intersexed man told Anne Fausto-Sterling of the experience of being masturbated by doctors in his childhood in order to measure penile growth and function — apparently a not uncommon practice. Probably the worst form of abuse, though, is the effect of repeated vaginal dilation of intersexed girls. One mother interviewed by Kessler hoped that the doctors would delay vaginoplasty on her daughter until later. She expressed a fear that children might experience it as abuse, citing the case of another woman whose 18 month old daughter had been pulling out her eyelashes and biting her nails in response to the dilation. Kessler asks: ‘Do physicians suppose that a young child understands that a painful, humiliating procedure done for “appropriate medical purposes” is not sexual abuse?’ (p. 63).
Given that creating a vagina can take several operations this procedure can dominate much of a child’s life. Older, adolescent, girls are supposed to take responsibility for dilating themselves. While doctors admit that this imposes a psychological burden on them, they nonetheless see a patient’s refusal to comply as a sign of immaturity or inadequate counselling. They take the same attitude to those who refuse further surgery, whether to enlarge the vagina or further reduce the clitoris — rarely do they question the supposed ‘need’ for repeated surgery. Large numbers of intersexed patients are recorded as ‘lost to follow-up’, but medics see this as a failure in their patients rather than in the treatment on offer.
Keeping children in their gendered place
The management of intersexed children does not end in infancy. Not only does it often entail further surgery and hormone therapy, but it also means giving children some sort of comprehensible account of what is happening to them. Such accounts are, however, rarely honest since it is assumed that it might be psychologically damaging for them to know the truth. They are therefore consistently deceived and misled about the real reasons for the ‘treatment’ they are receiving. Often they are not told the whole truth even when they reach adulthood.
One particularly dramatic case recounted by Anne-Fausto Sterling is that of ISNA activist Alice Moreno. In 1985, at the age of twelve, her clitoris grew to 1.5 inches in length. She was unperturbed by this, but her mother noticed and took her to a doctor. She was told she had cancer and needed a hysterectomy:
When she awoke from surgery, however, her clitoris was gone. Not until she was twenty-three did she find out she was XY and had testes, not ovaries. She never had cancer. (Sexing the Body p. 84)
Less cruel forms of deception can also be damaging. In an anonymous letter sent to the BMJ in 1994, one woman told how she had never been given any information about her condition — she had pieced together bits and pieces from casual remarks by doctors and nurses and then, in adolescence, gone to a medical library to find out for herself. Far from being comforted by the evasiveness of the medical profession, she felt betrayed — and called for more openness and honesty in the treatment of intersexed children (see Sexing the Body p. 84).
Adult intersexuals are now actively campaigning for greater honesty, but they face an uphill struggle. One problem with changing medical practice is that doctors, as we all know, do not have the same ideas about honesty and openness as the rest of us. They are used to giving patients sketchy and partial accounts of their medical conditions, practiced at evading questions and silencing patients who want to know too much. Consider how much worse the situation is where there is a medical rationale for denying the truth. Kessler’s data suggests that doctors are sometimes not even aware of being dishonest. An endocrinologist gave Kessler an account of what he had said to a fourteen year old girl with XY chromosomes. He told her that ‘her ovaries weren’t normal and had been removed’ — this is why she needed hormone pills. He went on:
I wanted to convince her of her femininity. Then I told her she could marry and have normal sexual relations…[Her] uterus won’t develop but [she] could adopt children. (Lessons from the Intersexed p. 29)
Kessler ran this explanation past other doctors in her sample, none of whom thought it was problematic. One said ‘He’s stating the truth, and if you don’t state the truth…you’re in trouble later.’ Given that this young woman had been born with testes rather than ovaries and had no uterus at all, this is, as Kessler says, a ‘strange version of “the truth”‘ (p. 29). Apparently this is a common explanation given to women with XY chromosomes, despite the fact that they might at some stage discover this. Kessler suggests that today’s increasingly litigious climate may force doctors to change — and some are beginning tentatively to suggest that greater honesty might be possible with older patients. Few, however, advocate total honesty at any stage.
FGM & IGM
Lied to, mutilated and abused, it is hardly surprising that intersexuals are becoming militant. Nor is it surprising that they should look for political allies. One parallel which could be drawn is with FGM, female genital mutilation. In 1997 the ISNA started to refer to intersex surgery as IGM, in order to make the comparison clear. They also hoped that that legislation to outlaw genital mutilation in the USA could be used to prevent surgery on intersexed children.
While the ISNA hoped to make common cause with those campaigning against FGM, they received no support from that quarter Suzaane Kessler reports that none of the major campaigners around FGM in the USA has been willing to consider genital mutilation of the intersexed as a related issue. Fran Hosken, author of The Hosken Report: Genital and Sexual Mutilation of Females wrote as follows to Cheryl Chase, founder of ISNA:
I am really dealing with quite a different topic from what you are interested in — that is, we are not concerned with biological exceptions, but rather with the excuses that are used to mutilate female infants that are both colorful and imaginative. (Quoted by Kessler, pp. 80-81).
To say this to a woman who has suffered complete excision of her clitoris must at least rank as insensitive. Kessler sees the distinction Hosken makes as spurious and there are certainly grounds for questioning it. Of course FGM and IGM take place in different contexts, have different meanings and consequences. There is a difference between societies where all girls are potential candidates for genital mutilation and those, like our own, where only those with unusual genitals suffer this fate. However, there are also commonalities beyond the mere facts of painful and damaging genital mutilation and lack of informed consent.
Both FGM and IGM are about constructing culturally appropriate genitals and acceptably gendered individuals. Most IGM entails making females and hence it could be argued that both FGM and IGM entail the control of women’s bodies, that both are underpinned by the assumption that female sexuality exists to service men. In both cases it could be argued that the genital mutilation is part of the apparatus of compulsory heterosexuality. Drawing a distinction between the two sets of practices might be a means of recognising cultural difference and specificity — but this can be double-edged. It can serve to render ‘exotic’ and ‘barbaric’ the mutilation of ‘other’ women, ‘elsewhere’ in the world without exposing the equally brutal mutilation performed under the cloak of clinical ‘necessity’ closer to home. For decades Black feminists have been warning us against pathologising practices such as FGM while failing to look critically at our own damaging cultural practices. Drawing out the similarities between IGM and FGM might be a way of avoiding this.
Gender and heterosexuality
Medical practice assumes, in Anne Fausto-Sterling’s words that ‘a healthy intersexual is a straight intersexual’ (p. 71). Surgical intervention to create femaleness clearly takes for granted women ‘need’ a ‘functional’ vagina — one large enough to be penetrated by the average penis — while treating a functional clitoris as an optional extra. Conversely a male must have a penis large enough for penetration — and doctors are clear that they mean vaginal penetration. Moreover, doctors evaluate psychological adjustment in adulthood in terms of heterosexual orientation — if an intersexed woman turns out to be a lesbian, they have failed. Clearly, where intersex is concerned — as elsewhere — gender and sexuality are closely intertwined.
Anne Fausto-Sterling goes further than this in suggesting that it is because of the social and political impulse to regulate sexuality that there is so much concern about keeping us within the boundaries of a binary gender system. This is certainly one reason why gender is so rigidly controlled, but I am wary of attributing the existence of a gendered social order entirely to the maintenance of heterosexuality. Suzanne Kessler suggests that the relationship may work the other way around: that certain genitals are defined as necessary markers of gender and that gender is then further validated by using those genitals heterosexually. However we theorise the link between gender and heterosexuality, though, it is clear that the problems faced by intersexed children are unlikely to be solved while we still have a rigid gender division.
Some see the problem here as one of the binary divide — suggesting that if we permitted more genders or more fluid gender boundaries there would be a place for all those who do not fit easily either as men or as women. This argument is commonly stated by Queer theorists and those interested in transgender as a form of gender outlawism. It is also the position Anne Fausto-Sterling took in earlier articles on intersexuality, arguing for up to five genders reflecting the variability of genitals. In Sexing the Body, however, she concedes ground to Kessler’s critique of this position, noting that it still gives genitals in and of themselves too much importance. Kessler goes further and suggests that if we focus on ‘cultural’ genitals we can begin to see that genitals have importance only because of their social significance, and they are socially significant because they provide a bodily grounding for gender oppression. It makes no sense to her (or to me) that we multiply gender categories. Instead, she says, we ‘must use whatever means we have to give up on gender’ (p. 132).
Kessler arrives at this conclusion, as I indicated at the outset, from a perspective that differs from my own. She focuses on gender as an interactional accomplishment, whereas I tend to see it primarily as a structural hierarchy. In a sense, though, it is both of these things. The point I would make is that we can’t challenge a hierarchical system by creating more positions or ranks within it. Where Kessler and I agree is that in the absence of gender intersexuality would finally really disappear: variant genitals would no longer matter socially and there would be no grounds for their compulsory surgical mutilation.
Anne Fausto-Sterling Sexing the Body: Gender Politics and the Construction of Sexuality (Basic Books, 2000)
Suzanne J. Kessler Lessons From the Intersexed (Rutgers University Press, 1998)
Pat Califia Sex Changes: The Politics of Transgenderism (Cleis Press, 1997)
Anne Fausto-Sterling Myths of Gender ( Basic Books, 1985/1992)
Suzanne J. Kessler and Wendy McKenna Gender: An Ethnomethodological Approach (Chicago University Press, 1978)
Ann Oakley Sex, Gender and Society (Martin Robertson, 1972)
Mariah Burton Nelson ‘Unfair Play: Sex Testing of Women In Sport’ Trouble & Strife 29/30 1994/5
Mariah Burton Nelson The Stronger Women Get the More Men Love Football: Sexism and the Culture of Sport (The Women’s Press, 1996)