States or Western Europe. The attending physician, realizing that the newborn’s genitalia are either/or, neither/both, consults a pediatric endocrinologist (children’s 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 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.
Why this rush to judgment? How can 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 affect the child’s future?
Since the 1950s, psychologists, sexologists, and other researchers have battled over theories about the origins of sexual difference, especially gender identity, gender roles, and sexual orientation. Much is at stake in these debates. Our conceptions of the nature of gender difference shape, even as they reflect, the ways we structure our social system and polity; they also shape and reflect our understanding of our physical bodies. Nowhere is this clearer than in the debates over the structure (and restructuring) of bodies that exhibit sexual ambiguity.
Oddly, the contemporary practice of ‘‘fixing’’ intersex babies immediately after birth emerged from some surprisingly flexible theories of gender. In the 1940s, Albert Ellis studied eighty-four cases of mixed births and concluded
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 development of masculinity, femininity, and inclinations toward homo — or heterosexuality, 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 Agreeing with Ellis’s 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 gonads, hormones, and chromosomes did not automatically determine a child’s gender role: ‘‘From the sum total 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 hermaphrodites to prove that nature mattered hardly at all. But they never questioned the fundamental assumption that there are only two sexes, because their goal in studying intersexuals was to find out more about ‘‘normal’’ development.6 Intersexuality, in Money’s view, resulted from fundamentally abnormal 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 1969, when Christopher Dewhurst (Professor of Obstetrics and Gynecology 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 Sheffield 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 mystique’’—the post—World 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 hysterical tone of Dewhurst and Gordon’s book, which contrasts markedly with the calm and reason of Young’s founding treatise.
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figure 3.1: A six-day old XX child with masculinized external genitalia. (Original photo by Lawson Wilkins in Young 1961 [figure 23.1 ,p. 140^]; 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 baby’s genitals. They employ the rhetoric of tragedy: ‘‘One can only attempt to imagine the anguish of the parents. That a newborn should have a deformity. . . (affecting) so fundamental an issue as the very sex of the child… is a tragic event which immediately conjures up visions of a hopeless psychological misfit doomed to live always as a sexual freak in loneliness and frustration.’’
They warn that freakhood will, indeed, be the baby’s fate should the case be improperly managed, ‘‘but fortunately, with correct management the outlook is infinitely better than the poor parents—emotionally stunned by the event—or indeed anyone without special knowledge could ever imagine.’’
Luckily for the child, whose sweet little genitalia we are invited to examine intimately (figure 3.1), ‘‘the problem was faced promptly and efficiently by the local pediatrician.’’ Ultimately, readers learn, the parents received assurance that despite appearances, the baby was ‘‘really’’ a female whose external genitalia had become masculinized by unusually high levels of androgen present 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 fifty-year — old who had lived h/her life as a woman, again treating the reader to an intimate close-up of the patient’s genitalia,9 which shows a large phallic-like clitoris, 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 fifty-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 management.’’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 corrected 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 specific procedures discussed in this book, but individual surgeons make decisions based on their own beliefs and what was current practice when they were in training—which 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 homosexuality in normal development.