Chapter 3: Of Gender and Genitals: The Use and Abuse of the Modern Intersexual [6]

gency.’’ The following are typical quotes from medical articles on intersexual­ity: ‘‘Ambiguous sex in the newborn infant is a medical emergency’’ (New and Levine 1981 ,p. 61); ‘‘Although it is now well-accepted that ambiguity of the genitalia is a medical emergency, this was not the case a decade ago’’ (Lobe, etal. 1987, p. 651); ‘‘Gender assignment is a neonatal surgical emer­gency’’ (Pinter and Kosztolanyi, 1990 p. 111). One surgeon called ‘‘the child with ambiguous genitalia a neonatal surgical emergency’’(Canty 1977, p. 272). The goal of one surgeon is to make a gender assignment within twenty — four hours and ‘‘send the child out as a sex’’ (Lee 1994, p. 30). Rink and Adams (1998) write: ‘‘One of the more devastating problems that can befall new parents is the finding that their child has ambiguous genitalia. This is truly an emergency necessitating a team approach by the neonatologist, endo­crinologist, geneticist, and pediatric urologist’’ (p. 212). See also: Adkins 1999.

2 . One physician believes that ‘‘after stillbirth, genital anomaly is the most serious problem with a baby, as it threatens the whole fabric of the per­sonality and life of the person.’’ Apparently things like mental retardation, severe physical impairment necessitating lifelong dependence and life-threat­ening illness pale before having a baby with mixed genitalia (Hutson 1992 p. 239). The American College of Surgeons implies that the consequences of a little girl being born with an extremely large clitoris are alarming enough that surgery must be done even if there is serious risk from administering anesthesia. Dr. Richard Hurwitz notes that most genital surgeries are per­formed after six months to minimize anesthesia risks; ‘‘if the clitoris is very large, however, it may need to be taken care of earlier for social reasons’’ (ACS-1613: ‘‘Surgical Reconstruction of Ambiguous Genitalia in Female Children,’’ 1994).

3. Ellis 1943; emphasis in the original.

4. Money 1932, p. 8. See also Money and Hampson 1933; Money et al. 1933a; Money 1933; Money et al. 1933b, Money et al. 1936; Money 1936; Money et al. 1937; Hampson and Money 1933; Hampson 1933; and Hampson and Hampson 1961.

3. Money etal. 1933a, p. 308.

6. More recently, in the foreword to Money 1994, Louis Gooren, M. D., wrote, ‘‘normalcy in sex is a basic human demand. Male and female created he them’’ (p. ix).

7. Kessler notes the following unexamined assumptions in Money’s work: (1) genitals are naturally dimorphic, and genital categories are not socially constructed; (2 ) genitals that are not dimorphic can and should be altered by surgery; (3) gender is necessarily dichotomous because genitals are naturally dimorphic; (4) dimorphic genitals are the essential markers ofgender dichot­omy; and (3) physicians and psychologists have legitimate authority to define the relationship between gender and genitals (Kessler 1998, p. 7). In this de-

tailed yet accessible book, Kessler systematically dissects each of these unac­knowledged assumptions.

8. Dewhurst and Gordon 1963^.1.

9. This seems to be a convention of the genre; the reader sees the most intimate photographs, shots that would be viewed as pornographic if set in Hustler rather than a medical book. Indeed, in researching this book, I often found gaping holes in medical texts where photographs of intersexuals and/ or their genitalia had been razored out by a previous reader. Interestingly, we always see the ‘‘before’’ shot, designed to illustrate sexual ambiguity, but less often the ‘‘after,’’ in which one is to presume that all traces of difference have been eliminated. Thus the reader can judge ‘‘nature’s’’ caprice but not the physician’s handiwork. Figure 3.1 is a rare photograph of a whole infant.

10. Dewhurst and Gordon 1963, p. 3. The reader never learns what the ‘‘woman’’ has done in the thirty years since her ‘‘limited adjustment’’ to the time of outbreak of new torment. It is unclear whether she married, or how she earned her living.

11. This narrative is based on my readings of case histories, physician training manuals, interviews, and journal articles.

12. Orgasm, of course, is a whole-body experience, not restricted to the penis or clitoris, but most modern sexologists agree that the phallus is the origin point for this pleasurable physiological response.

13. Baker 1981, p. 262. According to Baker, the first three minutes of doctor-parent interaction are critical.

14. For full documentation and a much more detailed account of the stan­dard script that physicians offer to the parents of intersex children, see Kes­sler 1998.

13. I believe the distinction between true and pseudo-hermaphroditism should be dropped and the general term intersexuality substituted. The authors of one medical text reviewing disorders of sexual development now use four major categories: disorders of gonadal differentiation, female pseudo­hermaphroditism, male pseudo-hermaphroditism, and unclassified forms of abnormal sexual development. They have demoted the term true hermaphrodit­ism to a subcategory under the heading of ‘‘disorders of gonadal differentia­tion’’ Conte and Grumbach i989,p. 1,814; table reprinted with permission).

I. Disorders of Gonadal Differentiation

A. Seminiferous tubule dysgenesis and its variants (Klinefelter Syndrome)

B. Syndrome of gonadal dysgenesis and its variants (Turner Syndrome)

C. Familial and sporadic XX and XY gonadal dysgenesis and their variants

D. True hermaphroditism

II. Female Pseudo-hermaphroditism

A. Congenital virilizing adrenal hyperplasia

B. Androgens and synthetic progestins transferred from maternal circu­lation

C. Malformations of intestinal and urinary tract (nonadrenal form of fe­male pseudo-hermaphroditism)

D. Other teratologic factors

III. Male Pseudo-hermaphroditism

A. Testicular unresponsiveness ofhCG and LH (Leydig cell agenesis or hy­poplasia)

B. Inborn errors of testosterone biosynthesis

1. Errors affecting synthesis of both corticosteroids and testosterone (vari­ants of congenital adrenal hyperplasia)

a. Cholesterol side chain cleavage deficiency (congenital lipoid adrenal hy­perplasia)

b. 3-P-hydroxysteroid dehydrogenase deficiency

c. 17-alpha-hydroxylase deficiency

2. Errors primarily affecting testosterone biosynthesis

a. 17,20-lyase deficiency

b. 17-alpha-hydroxysteroid oxidoreductase deficiency

C. Defects in androgen-dependent target tissues

1 . End-organ resistance to androgenic hormones (androgen receptor defects)

a. Syndrome of complete androgen resistance and its variants (testicular feminization)

b. Syndrome of partial androgen resistance (Reifenstein Syndrome)

c. Androgen resistance in infertile men

2 . Inborn errors in testosterone metabolism by peripheral tissues

a. 52 -alpha-reductase deficiency—male pseudohermaphrodism with nor­mal virilization at puberty (familial perineal hypospadias with ambiguous de­velopment of urogenital sinus and male puberty)

D. Dysgenetic male pseudohermaphroditism

1. X chromatin-negative variants of the syndrome of gonadal dysgenesis (e. g., XO/XY, XYp-)

2. Incomplete form of familial XY gonadal dysgenesis

3 . Associated with degenerative renal disease

4. Vanishing testes syndrome (embryonic testicular regression)

E. Defects in synthesis, secretion, or response to mullerian duct inhibi­tory factor:

Female genital ducts in otherwise normal men—uteri herniae inguinale; persistent mullerian duct syndrome

F. Maternal ingestion of progestins

IV Unclassified Forms of Abnormal Sexual Development

A. In males

1. Hypospadias

2. Ambiguous external genitalia in XY males with multiple congenital anomalies

B. In females

і. Absence or anomalous development of the vagina, uterus, and fallopian tubes (Rokitansky Syndrome)

16. Money 1968.

17. I have distilled the information presented here from the following sources: Gross and Meeker 1955; Jones and Wilkins 1961; Overzier 1963; and Guinet and Decourt і969.

18. Federman i967,p. 61.

19. Each of the three categories of intersex may in turn be subdivided. The medical researchers Paul Guinet and Jacques Decourt separated ninety — eight well-described cases of true hermaphroditism into four major types. Members of the first group (16 percent of the cases) exhibited ‘‘very advanced feminine differentiation’’ (Guinetand Decourt i969,p. 588). They had sepa­rate openings for the vagina and urethra and a cleft vulva defined by both the large and small vaginal lips. At puberty they developed breasts and usually menstruated. Their oversized and sexually alert clitoris, which at puberty sometimes threatened to grow into a penis, usually impelled members of this group to seek medical attention. In fact, even through the 1960s some inter­sexes raised as girls first drew medical attention because they frequently mas­turbated, an activity deemed unseemly for the female. Members of Group II (15 percent) also had breasts, menstruation, and a feminine body type. But their vaginal lips fused to form a partial scrotum. Their phallus (a structure found in the fetus that most frequently becomes either a clitoris or a penis) was from 1.5 to 2.8 inches long, but they urinated through a urethra located in or around the vagina. Most often, true hermaphrodites (55 percent) appear in a more masculine physique. The urethra runs either through or near the phallus, which looks more like a penis than a clitoris. Any menstrual blood exits periodically during urination (a phenomenon known as hematuria, or bloody urine). The vagina (without labia), which opens above a normal­looking scrotum, is often too shallow to permit heterosexual intercourse. Despite the relatively male appearance of the genitalia, however, breasts ap­pear at puberty, as is true for the last group (13 percent), whose phallus and scrotum are completely normal and who have only a vestigial vagina.

Internally, virtually all true hermaphrodites have a uterus and at least one oviduct in various combinations with sperm transport ducts. The data on chromosomal composition are not completely reliable, but it seems that most often true hermaphrodites have two X chromosomes. Quite rarely they are XY, and occasionally they contain mixtures of XX and XY tissue (or other more bizarre groupings of X and Y chromosomes) (Federman 1967). These data are unreliable in that it is virtually impossible with limited tissue sam­pling to eliminate the possibility of genetic mixtures—i. e., mosaics. The most up-to-date work in this arena uses molecular approaches, which can demonstrate the presence or absence of particular genes that are too tiny to

see under the microscope. Evenhere, however, the problem of tissue sampling remains. See, for example, Fechner et al. 1994 and Kuhnle et al. 1994.

20. Blackless et al. 2000, see the list in note 15.

21. The many technical reasons for this can be found in Blackless et al. 2000.

22. As with any genetic trait, different populations have different gene frequencies. Thus my account of albinism is true for the United States but not necessarily for some parts of the world where the albinism gene is more common. The estimate of intersexual births ‘‘requiring’’ surgery comes close to the frequency of cystic fibrosis—1 in 2,500 sufferers—in Caucasian popu­lations.

23. New et al. 1989, pp. 1,888, 1,896; Blackless et al. 1999.

24. Such so-called chimeric embryos are commonly produced by scien­tists studying development in model organisms such as mice. In this case, of course, the chimera was an accident. But given the increase in the number of in vitro fertilizations, such events are bound to happen again (Strain et al. 1998).

25. On environmental estrogens, see Cheek andMcLachlan 1998; Clark etal. i998;Dolketal. 1998; Goldenetal. 1998; Landriganetal. 1998; Olsen etal. 1998 ;Santti etal. 1998; Skakkebaek et al. 1998; and Tyler et al. 1998.

26. The increasing interest among academics in the notion of the cy­borg—part human, part machine—attests to such changes. Humans have pacemakers, artificial hearts, estrogen implants, plastic surgery, and more. Haraway 1991 provides the groundbreaking volume. See also Downey and Dumit 1997.

27. Learning about a child’s chromosomes or genitalia sometimes initi­ates a process of gender definition well before birth. Rapp insists that we listen to the diversity of women’s voices and not assume that we will always be the passive victims of new reproductive technologies (Rapp 1997).

28. Butler i993,p. 2.

29. Speiseretal. 1992; Laue and Rennert 1995; Wilson et al. 1995 ;We- dell 1998; and Kalaitzoglou and New 1993.

30. Laue and Rennert i995,p. 131 and New 1998.

3i. The earliest method involves testing a tissue sample taken from the chorion, one of the protective membranes surrounding the fetus.

32. Laue and Rennert i995,p. 131.

33. Unexpectedly, and for reasons not yet understood, some XY children with CAH have partially feminized genitalia (Pang 1994).

34. See the treatment protocol flow diagrams in Karaviti etal. 1992; Mer­cado et al. 1995; and New 1998.

35. More than a few uncertainties about timing still exist. One study re­ports the birth of a genitally female child, even though dexamethasone treat­ment did not begin until sixteen weeks of development (Quercia et al. 1998).

36. Mercadoetal. 1993.

37. Lajicl etal. 1998.

38. The tests are either sampling of the chorion or the better-known am­niocentesis.

39. Pang 199^ pp. i63-66.

40. Trautman et al. 1993.

41. Seckl and Miller i997,p. i,077. These authors also write: ‘‘The eth­ics of needlessly subjecting 7 of 8 fetuses at risk for CAH to an experimental therapy with unknown long-term consequences remain unresolved, and the long-term safety and outcome have not been established. Therefore, such pre­natal treatment remains an experimental therapy’’ (p. 1,078).

42. Mercadoetal. 1993.

43. Trautman et al. 1996.

44. See, for example, Speiser and New 1994 a, b.

43. Donahoeetal. 1991.

46. іЬі^ p. 327.

47. Lee I994, p. 38.

48. Flatau et al. 1973. Recently, standards have been published for penis size in premature infants. Does this mean we will start to see genital surgery on premature infants? See Tuladhar et al. 1998. The concern is that a micro­penis unrelated to the prematurity be recognized right away so that treatment or sex reassignment will not be delayed.

49. Donahoeetal. 1991.

30. I owe this phrase to Leonore Tiefer, who has written persuasively about the normalization of demands for certain types of sexual function. The upsurge of demand for Viagra suggests that the idealization of penile function does not reflect the norm of daily life (Tiefer i994aand 1994b).

31. These authors note that theirs is the first study of the normal distribu­tion of the urethral opening and should form a basis for deciding whether hypospadias surgery is needed (Fichtner et al. 1993).

32. The assertion comes from the American Council of Surgery, training tape ACS-1613: ‘‘Surgical Reconstruction of Ambiguous Genitalia in Female Children’’ (1994).

33. Newman et al. 1992a, write that what matters ‘‘is the presence of a . . . phallus sufficient in size to function as a male urinary conduit, to offer a satisfactory appearance when compared to peers, and to function satisfacto­rily for sexual activity’’ (p. 646); see also Kupfer et al. 1992, esp. p. 328.

34. Donahoe and Lee i98 8,p. 233.

33. Obsession with organ size is not universal. The Greeks thought the smaller penis to be more manly and sexy.

36. Kessler i998.

37. Sripathi et al. i997, pp. 786—87. A commentator on this example wrote: ‘‘It has to be accepted that attitudes towards sex of rearing and in par­ticular toward feminizing genitoplasties in late-diagnosed patients with CAH in the Middle East is going to be very different from those in Europe’’ (Frank i997, p. 789). See also Ozbey 1998; and Abdullah et al. 1991.

58. Kessler i99o, pp. 18—19.

59. Hendricks 1993, p. 13. For more on the attitudes of some surgeons, see Miller 1993.

60. See, for example, the discussions of clitoral size in Kumar et al. 1974.

61. Riley and Rosenbloom 1980.

62. Oberfield et al. 1989; see also Sane and Pescovitz 1992.

63. Lee I994, p. 59.

64. Doctors refer to such cases as ‘‘idiopathic clitoromegaly’’—that is, the clitoris is enlarged for unknown reasons.

65. Gross et al. 1966.

66. Fausto-Sterling 1993c.

67. See Dr. Milton T. Edgerton’s discussion in Sagehashi 1993, p. 956; Masters and Johnson 1966. Ina 1994 telephone interview, Dr. Judson Randolf told me he developed the less drastic operation for clitoral recession after one of his surgical nurses questioned the need for complete clitorectomy.

68. Randolf and Hung i97o, p. 230.

69. Smith 1997.

70. Steckeretal. i98i, p. 539.

7i. The following is a sample of the most recent publications on hypo­spadias: Abu-Arafeh et al. 1998; Andrews et al. 1998; Asopa 1998; Calda — mone et al. 1998; De Grazia et al. 1998; Devesa et al. 1998; Dolk 1998; Dolk et al. 1998; Duel et al. 1998; Fichtner et al. 1998; Figueroa and Fitzpatrick 1998; Gittes etal. 1998; Hayashi, Maruyama, etal. 1998; Hayashi, Mogami, et al. 1998; Hoebeke et al. 1997; Johnson and Coleman 1998; Kojima et al. 1998; Kropfl etal. 1998; Lindgren etal. 1998; Njinou etal. 1998; Nonomura etal. 1998; Perovic 1998; Perovic and Djordjevic 1998; Perovic, Djordjevic, et al. 1998; Perovic, Vukadinovic, et al. 1998; Piro et al. 1998; Retik and Borer 1998; Rosenbloom 1998; Rushton and Belman 1998; Snodgrass et al. 1998; Titley and Bracka 1998; Tuladhar et al. 1998; Vandersteen and Hus — mann 1998; and Yavuzer et al. 1998. A multiyear search of Medline using the entry word hypospadias located well over 2,000 medical publications on the topic. For an accurate defense of hypospodias surgery see Glassberg, 1999.

72. See, for example, Duckett and Snyder 1992; Gearhart and Borland 1992; Koyanagi et al. 1994; Andrews et al. 1998; Duel etal. 1998; Hayashi, Mogami, etal. 1998; Retik and Borer 1998; Vandersteen and Husmann 1998; Issa and Gearhart 1989; Jayanthi et al. 1994; Teague et al. 1994; and Ehrlich and Alter i996.

73. Duckett i996,p. 134.

74. Hampson and Hampson write: ‘‘body appearance does have an impor­tant, indirect bearing on the development of psychologic functioning, in­eluding that which we term gender role or psychosexual orientation’’ Hamp — son and Hampson 1961 ,p. 1,415.

75. Ibid. , p. i,4I7.

76. Peris i960, p. 165.

77. Slijperetal. i994,pp. io-ii.

78. Ibid., p. i4.

79. Leeetal. i98o, pp. i6i-62.

80. Forest i98i, p. i49.

81. For an argument against early gonadeetomy, see Diamond and Sig — mundson i997a.

82. Kessler i99o, p. 23.

83. They wrote: ‘‘the sex of assignment and rearing is consistently and conspicuously a more reliable prognosticator of a hermaphrodite’s gender role and orientation than is the chromosomal sex, gonadal sex, the hormonal sex, the accessory internal reproductive morphology, or the ambiguous morphol­ogy of the external genitalia’’ (Money et al i957, pp. 333—34).

84. This is at odds with the mother’s statements thirty years later, when she confirmed John’s memories of trying to rip off his frilly dresses. Memory and interpretation of a third party often pose difficulties in evaluating the utility of evidence from case studies.

85. Money and Ehrhardt i97 2,pp. i44—45,p. i52. Money said he wanted to root out the nineteenth — and early-twentieth-century ‘‘tyranny of the go­nads’’ (Dreger i998b), which he felt often led to a sex assignment that was psychologically unwarranted. This rhetoric, however, does not really ring true, since physicians such as W H. Young, whose work Money had to have known, had long since let go of using gonads alone to assign sex. Perhaps Money simply wanted to bring this work to a larger and still benighted audi­ence of practitioners out in the boondocks. Perhaps, too, he was merely riding a larger wave of i95os neo-Freudian psychology that emphasized the impor­tance of a ‘‘proper family’’ and role models provided by a bread-earning dad and a stay-at-home mom. It will require more historical work to figure out exactly what Money’s ideological commitments were and how they shaped his studies.

86. It is not clear why such a seemingly radical viewpoint gained such complete control of the medical discourse, making it impossible until very recently to challenge Money and his colleagues’ approach to the treatment of intersex. Kessler writes: ‘‘Unlike the media, my interest in this case is not whether it supports a biological or a social theory of gender development but why gender theorists (including McKenna and myself) were too eager to embrace Money’s theory ofgender plasticity. Why also did it become the only theory taught to parents of intersexed infants?’’ (Kessler i998,p. 7).

87. In the acknowledgment of his paper, Diamond writes, ‘‘I am indebted to Robert W Goy, who originally suggested the writing of this paper, and to Drs. William C. Young, Charles H. Phoenix, and Arnold A. Gerall for enlightening discussion of the theories and problems involved in a presenta­tion of this type’’ (Diamond 1965^. 169) Zucker writes: ‘‘Thus in a wonder­fully dialectical manner, while Money and his colleagues were emphasizing the importance of psychosocial factors on aspects of psychosexual differenti­ation in humans, a method, a paradigm, and a theory of biological factors on psychosexual differentiation in lower animals were also being articulated’’ (Zucker 1996, p. 151).

88. Later, Robert W Goy extended this approach to studies of rhesus monkeys. This paradigm is articulated in its most influential form in Phoenix et al. 1959. I discuss the paradigm and this paper in detail in chapter 8.

89. The history of this organizational/activational theory in rodents is another story (see chapter 8 of this book), and the extent of its applicability to primates is still a matter of contention (see Bleier 1984 and Byne 1995).

90. Diamond 1965.

91. Ibid., pp. 148, 150; emphasis added.

92. Diamond wrote: ‘‘although humans can adjust to an erroneously im­posed gender role, (a) it does not mean that prenatal factors are not normally influential, and (b) that they do so with difficulty if not prenatally and biologi­cally disposed.’’ He also argued that humans share a common vertebrate heri­tage and should thus be expected to have developmental systems similar to other animals (Diamond 1965^. 150; emphasis in original).

93. Diamond’s characterization of Money’s theory seems inaccurate to me. His depicts a psychosexually undifferentiated child whose gender identity seems to develop only in response to environmental upbringing. At first, it seems, there is complete choice about gender identity, but after a critical pe­riod in early childhood in which choice becomes restricted, new learning ex­periences would ‘‘enlarge and direct sexual development’’ (idem, p. 168). Money’s actual position shifted with time, and even in his early publications he did not always support the idea of complete neutrality at birth. In order to distinguish clearly his own model, Diamond chose the most extreme version of Money’s sometimes inconsistent ideas. On this point, see also Zucker 1996.

94. Diamond 1965^. 168.

95. His work was published, followed by Money’s negative review of the paper (Zuger 1970; Money 1970). There was also a brief, unanswered paper in the British Medical Journal published in 1966. It also provides a rare firsthand account of how delighted the child was to change from female to male at age thirteen, and his later successful development and marriage (Armstrong 1966).

96. Zuger i970,p. 461.

97. Money includes Diamond in his list of negative examples (Money ^70 p. 464).

98. Money and Ehrhardt i972,p. 154. Money and Ehrhardthere citeboth Zuger and Diamond as negative examples.

99. Diamond 1982^.183.

100. Ibid. p. 184.

101. Quoted in Colapinto i997,p. 92.

102. Angier 1997b. Even in 1997, Money’s viewpoint was so widely ac­cepted that Diamond and Sigmundson could not, at first, get their paper pub­lished (Diamond, personal communication 1998).

103. Diamond and Sigmundson 1997b, p. 303; emphasis added. See also 1997a and Reiner 1997. In this passage Diamond has a hard time following his own advice to avoid using terms such as normal vs. mal-developed, see para­graph 3,p. i,046.

104. See, for example, Gilbert et al. 1993; Meyer-Bahlburg et al. 1996; Reiner 1996; Diamond 1997b; Reiner 1997a, b.; Phornputkul et al. 2000; VanWyk 1999; Bin-Abbas et al. 1999.

105. Cf. Diamond and Sigmundson 1997a and 1997b with Meyer — Bahlburg et al. i996;Zucker 1996; and Bradley et al. 1998.

106. Diamond and Sigmundson 1997b, p. 304. See also: Lee and Grup — puso 1999, and Chase 1999.

107. Bradley et al. 1998, pp. 6—8 of printout of electronic article.

108. Here are some of their comments: ‘‘I find it interesting that the au­thors … do not investigate the possible effects of ‘negative nurture’ . . . which seem to leap right off the page: while John had a well-adjusted male twin and a supportive, loving father, Bradley’s patient had an alcoholic father who left when she was 3—4 . . . followed by an alcoholic stepfather. No won­der she denied ever feeling that she had wanted to be male,’’ ‘‘At 26 I was— ostensibly—happily, heterosexually married to a man; had a team of doctors shown up to ask me how I was, that is most certainly what I would have told them. Two years later I was divorced and pursuing further corrective surgery to normalize [to make more male-like] my genitalia’’ to make me more attrac­tive to females. ‘‘I have been living as a male since March of 1998.’’ Several others commented that at twenty-six their gender identities were not yet ‘‘finished.’’ Indeed, a concept one finds throughout this debate is that there is but one true stable identity that individuals must find and live with. A sad case is one who never even knows his or her true identity (‘‘I’m sure he’s transsex­ual but he doesn’t know it’’).

Finally, intersexual commentators about both papers argued that ‘‘what is read as rejection of being regendered could also be the rejection of a traumatic situation vis-a-vis being intimately studied.’’ Despite the trauma of hospital­ization, surgery, and frequent genital exams, ‘‘the papers mentioned re­mained focused on the question of gender identity order/disorder rather than questions of personal bodily integrity and violation.’’ Only a few scholars in this field have raised the general question of how any surgical trauma early in development might affect later behavior and development. During this on­line debate, some of the sexologists politely thanked the intersexual corre­spondents for their thoughts, but none took on their substantive points. To do so would have made it even more difficult to interpret and thus enter medical case studies in the service of particular theories of gender formation.

109. Money 1998,pp. 113—14.

no. Berube i99o, p. 258.

in. Hampson and Hampson 1961, p. i,425. Money et al. 1956, p. 49, list three treated hermaphrodites as ‘‘mildly unhealthy’’ because they ‘‘had homosexual desires and inclinations.’’

112. Money et al. 1955b, pp. 291—92. ‘‘It is important,’’ one group writes, ‘‘that the parents have plenty ofopportunity to express. . . their fears for the future, such as. . . fear for an abnormal sexual nature. Parents will feel reassured when they know that their daughter can develop heterosexually just like other children and that male characteristics are impossible’’ (Slijper et al. 1994, pp. 14—15). Note here, too, how lesbianism is associated with maleness. See also Dittmann et al. 1992, who write: ‘‘In our clinical experi­ence many parents—some from the day of diagnosis on—are deeply con­cerned about the psychosexual development and sexual orientation of their CAH daughters. Thus we recommend… all these aspects of psychosexual development, sexual behavior and sexual orientation should be considered and included in the clinical and psychosocial care of CAH patients and their families’’ (p. 164). I, of course, agree that such matters must be part of the counseling and sex education offered to intersex families. My point here is that responsibility for concerns about homosexuality are attributed to the family, whereas the treatment team always presents itself as being liberally open — minded on such matters. Never have I come across a therapist or physician who, in the literature on intersexuals has written something like: ‘‘I used to think homosexuality was an unhealthy outcome but now I realize it is not. I have, therefore, changed my treatment approach and analysis in the follow­ing ways.’’

113. See Money and Ehrhardt 1972, chapters 7 and 8, for a comparison of matched pairs ofintersexuals who, according to the authors, develop different gender identities depending upon the sex of rearing. This type of case study comparison is rhetorically enormously powerful.

114. All of which lends credence to Suzanne Kessler and Wendy McKen­na’s argument that gender is socially constructed and sex a misleading term. They write that ‘‘the 2-bodied system is not a given—that people are respon­sible for it’’ Kessler and McKenna personal communication, 1998, see also Kessler and McKenna 1978; Kessler 1998. This does notmean, as some skep­tics might suggest, that people make bodies. It means they make the system that categorizes them, and a system of just two bodies is not the only possible system. As I discuss in the following chapter, a greater tolerance for sexual diversity may well lead to an era in which we no longer think of there being merely two sexes.

115. Money and Ehrhardt 1972, p. 235. Emphasis added. Money and Dalery (1976) write: ‘‘a formula for creating the perfect female homosexual… on the criteria of chromosomal and gonadal sex is to take a chromosomal and gonadal female fetus and to flood the system with masculinizing hormone during the. . . period when the external genitals. . . are being differentiated. Then assign the baby as a boy at birth’’ (p. 369). Note that in Money’s view, the perfect female homosexual has a penis and a masculinized brain! Kessler describes these situations in the following manner: ‘‘In what sense could a woman with a vagina who is sexually gratified by being penetrated by a ‘woman’ with a large clitoris (that looks and functions like a penis) be said to be a lesbian? If gendered bodies fall into disarray, sexual orientation will fol­low. Defining sexual orientation according to attraction to people with the same or different genitals, as is done now, will no longer make sense’’ Kessler i998,p. i25.

116. Diamond 1965, p. 158; Diamond and Sigmundson 1997a, pp. i,046—1,048. But see also some occasional slips, such as his use of the word normal here: ‘‘The evidence seems overwhelming that normal humans are not psychosexually neutral at birth but are, in keeping with their mammalian her­itage, predisposed and biased to interact with environmental, familial and social forces in either a male or a female mode’’ (idem, p. 303).

117. Kessler and McKenna 1978. They write: ‘‘We will use gender, rather than sex, even when referring to those aspects of being a woman (girl) or man (boy) that have traditionally been viewed as biological. This will serve to emphasize our position that the element of social construction is primary in all aspects of being female or male, particularly when the term we use seems awkward (e. g., gender chromosomes)’’ (p. 7).

118. Whether these differences really exist, when during development they might appear and how we can fairly measure them is not under discussion here. (See Fausto-Sterling 1992b).

Even where we agree on the existence of such differences, the question of their origin remains. Will we rely primarily on a biological model of differ­ence, in which gender is layered over a preexisting bodily foundation, which we call sex?

119. How, specifically, does this cash out in our ideas about masculinity, femininity, and sexual desire? To understand contemporary medical studies we must start, as is so often the case, with the Victorians. Men, our queenly forebears asserted, had active sexual desire, while women were passionless to the point of asexuality. Women’s inborn passivity, wrote the German sexolo­gist Richard von Krafft-Ebing, ‘‘lies in her sexual organization [nature/sex], and is not founded merely on the dictates of good breeding (nurture/gender)’’ (quoted in Katz 1995, p. 31). In this system of thought a woman who had strong sexual desire, especially if she desired another woman, had, by defini­tion, become masculine. To be a lesbian meant to invert the sexual order, to be a psychological and emotional man in a woman’s body. (Money and Dalery i976,p. 369). During the first quarter of the twentieth century, at least when writing about sex in marriage, sexologists such as Havelock Ellis acknowl­edged that women experienced sexual passion. Nevertheless, he and others applied the concept of the invert to women who behaved like men: they were aggressive, might smoke cigars, dressed like men, and took other women as love objects. The passive woman in a lesbian relationship did not appear to be lesbian. For a more detailed discussion of these points, see Chauncey 1989 and Jackson 1987. As Radclyffe Hall melodramatically displayed in her novel The Well of Loneliness (1928), the ‘‘passive’’ partner could as easily run off with a man. Some major theorists of male homosexuality also held firmly to a model of complete gender inversion. The German reformer and homosexual rights advocate Magnus Hirschfeld, for example, considered the male invert to be hermaphroditic in both mind and body. He searched not only for behav­ioral clues but for intermediate body types. For a time he teamed up with the hormone researcher Eugen Steinach, who delighted him by claiming to have found special cells in the testes of male homosexuals. These cells, they be­lieved, were responsible for producing hormones that feminized the invert in body and mind. Steinach’s hormone research is important in the construction of knowledge about supposed male and female hormones. I discuss his work in more detail in chapter 6. For a fascinating account of the collaboration between Hirschfeld and Steinach, see Sengoopta 1998.

120. Much of what follows could certainly be applied to work on differ­ences in spatial ability, but to avoid repetition of the principle point I will not discuss this work in detail. Some key references are Hines 1990; Hines and Collaer 1993; Sinforiani et al. 1994; and Hampson et al. 1998. Hines and Collaer suggest that any relationship between prenatal testosterone levels and increased spatial abilities could be secondary to hormone-influenced differ­ences in play patterns. They also find that data supporting the idea that sex differences in mathematics are caused by prenatal androgen exposure ‘‘are weak’’ (p. 19).

121. Abramovich et al 1987.

122. Magee and Miller 1997, p. 19. See also Fuss 1993 and Magid 1993. There is an alternate theory of male homosexuality as hypermasculinity (Sen­goopta 1998). According to some, such hypermasculinity explains why gay men in the modern U. S. are so sexually active. By analogy, lesbians may over­express female sexuality, seen as a lack of sexual desire. This viewpoint has been used to explain so-called lesbian bed death (Symons 1979).

123. In contrast, lowered androgen exposure and even severe penile hy­pospadias were not seen to ‘‘interfere with the development of gender-typical masculine behavior’’ in XY children (Sandberg and Meyer-Bahlburg 1995, P — 693)-

124. In an earlier work I critiqued many of these studies, as did Ruth Bleier (Fausto-Sterling 1992; Bleier 1984). A small number of very recent studies have responded to the critiques by including in their experimental design blind assessments of behavior or by trying to find appropriate con­trols—e. g., other children suffering from non-sex-related chronic illness. But on the whole, the design of all these studies leaves much to be desired. I do not plan to rehash the experimental problems here so much as I want to show how our gender system has dictated the design ofthese studies and lim­ited the interpretations of the data.

125. It could be otherwise. For example, there are orthogonal models of masculinity and femininity suggesting that masculinity and femininity are independent traits. Researchers using an orthogonal model might still study CAH girls. But they would look for different behaviors and use differently structured questionnaires (Constantinople 1973). Spence writes: ‘‘The mul­tidimensional nature of sex-role and other gender-related phenomena is also beginning to be recognized. Although gender identity may be essentially di­morphic, the general statement that masculine and feminine attributes and behaviors cannot or do not coexist has been effectively refuted’’ (Spence 1984). See also Bem 1993. Still other researchers might decide to use CAH girls to investigate the long-term effects of chronic illness and repeated sur­geries on gender-related play, rehearsal for adulthood, and postpubertal love object choice. Interesting effects of hormones could still emerge if they chose to compare hormonally caused chronic illness with other types.

126. Psychologists have often used the term tomboyism to define masculin­ity in CAH children. The imprecision of that term, perhaps after years of feminist critique, seems to have led recent writers to replace it with more specifically defined behavioral measures.

127. One set of studies distinguishes between the severe ‘‘salt-wasting’’ form of CAH, in which there do seem to be activity differences in affected girls, and the ‘‘simple-virilizing’’ form, for which masculine behavior is less pronounced. Many early studies did not distinguish between these two forms of the disease, which may well result in different behavior patterns. Explaining the behavioral differences presents the standard conundrum between biologi­cal and social possibilities. (See Dittmann et al. 1990a and 1990b).

128. Magee and Miller 1997, p. 83; Hines and Collaer 1993,p. 10.

129. Magee and Miller 1997. The pet care finding is from Leveroni and Berenbaum 1998. They offer several possible explanations—for example, that ‘‘CAH girls may spend more time with pets because they are less inter­ested in infants but not less nurturant overall than controls’’ (p. 335). This would imply that testosterone interferes with the development of interest in infants, but that some general character called nurturance, which could get directed everywhere but to children, existed independently of high andro­gen levels.

130. Magee and Miller i997,p. 87.

131. Dittmann et al. 1992^.164.

132. Hines and Collaer i993,p. 12.

133. In other words, they do ‘‘good science’’ by most measures (grants, publication, peer review, promotions). The science looks funny only if one acknowledges the possibility of other logical systems.

134. Consider a single study by the psychologists Sheri Berenbaum and Melissa Hines: Boys like to play with construction sets and trucks, but girls prefer dolls, dollhouses, and toy kitchen equipment. Many psychologists have found such average sex differences in studies of play preferences in young chil­dren. (Obviously the particular toys are culturally specific. However, sex differences in play preferences are culturally widespread, albeit differently expressed in different cultures). See also Maccoby, E., 1998. But how do such preferences come about? Berenbaum and Hines agree that children learn pref­erences from other children; but, they suggest, such learning cannot tell the entire story. ‘‘We present evidence that these sex-typed toy preferences are also related to prenatal or neonatal hormones (androgens)’’ (Berenbaum and Hines 1992, p. 203). Citing myriad animal studies showing the influence of hormones on the brain and behavior, they note that CAH girls present ‘‘a unique opportunity to study hormonal influences on human sex-typed behav­ior’’ (p. 203). In their introduction, the authors take note of the design defi­ciencies of previous work and vow in this study to do better. Specifically, they note four major problems (many of which both Bleier and I have raised as well (Bleier 1984, Fausto-Sterling 1992b). Previous studies (a) assessed behavior from interviews rather than direct observation, (b) were not done blind, i. e., those who assessed the data knew whether they were dealing with experimen­tal or control subjects, (c) assessed behaviors as present or absent rather than as part of a continuum, and (d) often treated masculine and feminine behav­iors as the far ends of a single continuum, rather than considering that they could both exist in the same individual.

They kept their vow. Compared to earlier studies, this one was, indeed, well done. One key difference (to which I will return shortly) was that Beren­baum and Hines considered the severity of CAH in the girls they observed. They looked, for example, at the age at diagnosis and the degree of genital virilization. They videotaped play sessions in which both boys and girls had access to male — and female-preferred toys as well as some gender-neutral op­tions (toys preferred equally by both sexes). Neutral toys included books, game boards, and jigsaw puzzles). Finally, they had videotapes rated by two separate raters, neither of whom knew the status or identity of the children whose play choices they counted.

Berenbaum and Hines’s major positive finding was that, compared to un­affected girl relatives, the CAH girls chose boys’ toys more often and played with them longer—as often and as long as did the boys. They also played less with girls’ toys, but not significantly so. They suggest this small effect size for CAH versus control in time spent with girls’ toys may be an experimental artifact (p. 204). Finally, and it is their treatment of this last point that I want to examine, ‘‘the amount of time spent playing with sex-typed toys was not significantly related to any disease characteristic’’ (pp. 204—05), including the degree of virilization. They do not give specific data on possible correlations with time of diagnosis, but this too would be important information. (I sus­pect their sample size was too small to say anything one way or another.) But this information might be of interest if one assumes that the longer a child goes untreated, the longer will have been her exposure to unusual levels of androgen, hence the greater the likelihood of seeing a hormone effect— if, indeed, such exists. Furthermore, postnatal hormone exposure could be quite interesting to study because in theory, it would afford scientists the chance to look at how hormones and experience might co-produce some be­havior patterns. This makes special sense for humans because so much critical brain development occurs after birth. But the framework of the animal re­search used by these investigators makes it much less likely that they will think to ask such questions, which really require a different frame of reference and research program. There are other animal behavior traditions that would logi­cally lead, to such types of questions. I discuss these in chapters 1 and 9 of this book. See also Gottlieb 1997.

Why should it matter if the degree to which CAH girls prefer boys’ toys correlates significantly with how virilized their genitalia are? Remember that they want to compare their work to a vast literature on animal development. In this experimental terrain, researchers know when in the developmental process they inject test hormones and at what concentrations. To define criti­cal developmental periods, they vary the time of injection and inject different amounts of hormone to show a dose response (the higher the dose, the greater the effect). Such experimental fine-tuning is impossible in human studies. For how long and at which developmental stages were these girls exposed to high androgen levels? We don’t know. What hormone levels were they exposed to? We don’t know. Such information, in the long run, is critical to interpreting the results of studies on CAH girls, but it is for all intents and purposes un­available. Hence the need to fall back on arguments from the animal literature and allusions to ‘‘our common vertebrate heritage’’ (Diamond and Sigmund — son 1997b) and to rely on imperfect but important internal controls.

One such control is the degree of virilization. The fetal testis begins to secrete androgens eight weeks after fertilization and continues at high levels even as their production begins to drop off during the second and into the third trimester. Under their influence the internal and external genitals de­velop (see figure 3.1). Usually, the overall shaping of a boy’s external organs occurs during weeks 9 to 12 of embryonic development, but growth and fine — tuning continues until birth and beyond. The genitalia, of course, grow slowly throughout childhood and more dramatically at puberty. Although the timing I describe is the statistical norm, it is not the only known developmental path­way. In one well-studied genetic variation, called 3-alpha-reductase defi­ciency, males are born with very feminine-looking genitals. But at puberty, the clitoris enlarges into a penis and the vaginal lips fuse to form a scrotum into which their testes descend. Given that fetal testosterone is present even in the third trimester (see graph on p. 292 of O’Rahilly and Muller 1996), possible effects on brain development could occur over a broad period of time, during which the central nervous system is developing apace.

CAH girls, of course, don’t have testes. It is their adrenal glands that mas­culinize their genitalia, but the timing of these events is uncertain. The lack of information on this point is in stunning contrast to the impressive detail available on the molecular aspects of the CAH family of enzyme malfunction. Dr. Maria New and her colleagues write: ‘‘Adrenocortical cell differentiation occurs early in embryogenesis, with the formation of a provisional fetal zone, active for the remainder of gestation, that involutes after birth. Although the schedule of evolving steroid synthesis in the fetal and adult (permanent) zones has not been completely elucidated, it is clear that genital development in the fetus takes place under the influence of active adrenal steroid biosynthesis’’ (New et al. 1989, p. 1,887; emphasis added). In other words, there are two sources of adrenal hormones: the fetal adrenal cortex, which develops toward the end of the second month of development, and the permanent, which develops late in fetal development. The fetal adrenal cortex regresses and disappears by one year after birth. O’Rahilly and Muller 1996 write: ‘‘The functions of the fetal cortex are not entirely clear, but its enormous size is believed to be associated with a similarly great capacity for steroid production’’ (pp. 324—23). In the extreme it is possible the CAH girls experience elevated androgens from eight weeks after fertilization until some time after birth—a different pattern of exposure than XY boys experience. Interfering with fetal adrenal androgen production during the first trimester can allow female genitals to develop, but there is a lot of variability in the anatomical effects of CAH (Mercado et al. 1993, Speiser and New 1994a, b). If the level of adrenal androgen overpro­duction is low, or if overproduction starts late in development, CAH girls will presumably have more feminized genitals. If hormone concentrations are extremely high or start very early in development, the genitalia may become highly masculinized. Suppose in Berenbaum and Hines’s study the degree of virilization had correlated with the degree ofboy toy preference. An embryol­ogist (such as myself) would argue that the result supported an argument that ‘‘early hormone exposure in females has a masculinizing effect on sex-typed toy preferences’’ (Berenbaum and Hines 1992). Why? Because if increased virilization measures heightened or prolonged androgen levels, and if andro­gen levels change behavior in an incremental fashion, then the more androgen (up to a point), the more of the measured behavior. What does it mean that they found no such correlation?

Here we arrive at the crux of the matter. For meaning to emerge from a set of data requires a frame of vision. My embryologist’s frame of vision led me to understand the degree of virilization as a possible measure of how much androgen exposure a particular CAH girl had experienced. But Berenbaum and Hines did not use the degree of virilization as a control for hormone dose. For them a positive correlation would have provided evidence against, notfor, their hypothesis. This is because some have suggested that parents might treat girls with penises differently than ones without penises. Or the children themselves might react to a more male-like body image. (I confess, in fact, that I am one of those who raised these possibilities. I did so from my other frame of reference—that of a feminist activist. This framework, I remind the reader, leads me to extreme skepticism toward theories focusing on the biological causes of behavior, especially sexual and racial differences that seem, always, to end up in the middle of discussions of social equality [Fausto — Sterling 1992]). As I write (mid-December 1998), for example, a discussion rages on Loveweb about the meaning of equal opportunity. Quoting anony­mously (and with changed names) from one of the participants, a highly re­spected researcher in the field of hormones and behavior: ‘‘John says he has no interest in eliminating sex differences. Susan says neither does she, but wants only equality of opportunity. The implication is that the existence of sex differences does not necessarily lead to inequality ofopportunity. I suspect there are some on this list who would argue that as long as sex differences exist, equality of opportunity cannot be achieved. Does this latter view reflect a belief that all sex differences are socially constructed and therefore embody inequality of opportunity? Thus my question. Do sex differences have to be eliminated to achieve equality of opportunity between the sexes? For exam­ple, will equal opportunity exist only when males and females can both ges — tate babies?’’

If parental behavior or altered body image were the key, the changed be­haviors might not result from the direct effects of hormones on the brain. Since there was no correlation, Berenbaum and Hines reasoned, there must be no difference in how parents socialized CAH girls and their unaffected relatives. (They did assess parental attitudes using a questionnaire, but felt their methods on this point left uncertainty. They noted that direct observa­tion of parent-child interaction, using blind assessments, would give more reliable information.) Thus they could safely conclude that androgens affect the developing male’s brain, leading him to prefer trucks and building blocks as a toddler. Hines and Collaer 1993 further consider this question. Again they use the lack of virilization to refute interpretations based on nurture cues, arguing instead for a direct effect of androgen on the developing brain. They do worry more about what the lack of correlation might mean in terms of the embryo: ‘‘In humans,’’ androgen levels are elevated in developing males compared to developing females from approximately week 8—24 of gestation and again from approximately the first to the sixth month of infancy. Because genital development occurs before brain development, one speculation would be that degree of genital virilization among CAH girls reflects the time of onset of the disorder, whereas behavioral changes reflect the degree of andro­gen elevation during later periods. If so, behavioral and physical virilization would correlate. Alternatively, the lack of a clear correspondence could relate to differences in enzymes needed to produce active hormones’’ (Hines and Collaer 1993, pp. 7—8). They also quote the single study (Goy et al. 1988) from primates (rhesus monkeys) in which one androgen-influenced behavior (rough play) is independent of the degree of virilization; others, such as mounting, correlate with levels of virilization. In this study the authors also found that mother rhesus monkeys inspected male genitals and masculinized female genitals a lot more often than they did unaffected female genitals. Fur­thermore, in this study, prenatal androgenization cannot produce a ‘‘pure’’ male behavioral response in masculinized females. Why? Possibly the andro­gen treatments weren’t at the critical period of brain development. Or possi­bly behavioral development is more complex and includes effects from postna­tal behavioral interactions. Note also how misleading is the title of Goy et al.’s paper: ‘‘Behavioral masculinization is independent of genital masculinization in prenatally female Rhesus monkeys.’’ Why not ‘‘Some behavioral masculini­zation is independent’’? Such a title would more accurately represent the con­tents of the paper. My biologist self is wrestling also with the validity of ex­trapolating studies on CAH children to unaffected male development. This is because the timing of hormone exposure is probably different. In most XY fetuses, testes make the hormones between months two and six with levels tapering off thereafter. In CAH fetuses, however, adrenal androgen produc­tion may begin during the latter third of the first trimester and continue until treatment begins (after birth). In one case hormone exposure is episodic, and in the other it is tonic. Brain development is continuous from the third week of development (and possibly until we die!). I have never seen a hypothesis about what region of the brain is suspected of being responsible for play, nur­turing, and other childhood behaviors. Thus it is impossible to know which periods of development might be critical in terms of hormone/brain interac­tion. It surprises me that even in the primate studies, the question of what is happening in brain development during the period of experimental hormone injection is not discussed. Later, others suggest, he or his CAH female coun­terpart may become more aggressive (Berenbaumand Resnick 1997), develop better spatial abilities (Hampson et al. 1998), be less interested in taking care of babies (Leveroni and Berenbaum 1998), and desire women as sex and love objects. For additional discussion of female object choice in CAH women, see Zucker et al. 1996.

135. Butler 1993, p. xi. For a related analysis of hermaphrodites at the limits of subjectivity, see Grosz 1966.

136. In this analysis, a man or a woman would be someone whose chro­mosomes, fetal gonads and hormones, fetal, child, and adult genitals, adult gonads, and sexual orientation were each and all culturally intelligible as either male or female. When one or more of these components of gender differ from the others (as with intersexuals), they become uninterpretable bodies—i. e., culturally unintelligible.

137. Butler i993,p. xi.

138. Sawicki 1991, p. 88. Lesbians using these technologies to create ‘‘natural’’ biological families is one good example.

Chapter 4: Should There Be Only Two Sexes?

1. Fausto-Sterling 1993a. The piece was reprinted on the Op-Ed page of the New York Times under the title ‘‘How Many Sexes Are There?’’ Fausto — Sterling 1994.

2. This is the same organization that tried to close down the Off Broadway play ‘‘Corpus Christi’’ (by Terence McNally) during the fall season of 1998 in New York City.

3. Rights 1993 Section 4, p. ii. The syndicated columnist E. Thomas McClanahan took up the attack as well. ‘‘What the heck,’’ he wrote, ‘‘why settle for five genders? Why not press for an even dozen?’’ (McClanahan 1993 p. B6). Pat Buchanan also joined the chorus: ‘‘They say there aren’t two sexes, there are five genders. … I tell you this: God created man and woman—I don’t care what Bella Abzug says’’ (quoted in TheAdvocate, October 31, 1993). Columnist Marilyn vos Savant writes: ‘‘There are men and there are women—no matter how they’re constructed. . . and that’s that’’ (vos Savant I996 p. 6).

4. Money i994.

3. Scott’s novel won the Lambda Literary Award in i993. She specifically acknowledged my work on her web site.

6. See, for example, Rothblatt 1995; Burke 1996; and Diamond 1996.

7. Spence has been writing for some time about the impossibility ofthese terms. See, e. g., Spence 1984 and 1985.

8. For activists working for change see the Intersex Society of North

America (http://www. isna. org) and Chase i998a, b; and Harmon-Smith 1998. For academics in addition to myself, see Kessler 1990; Dreger 1993; Diamond and Sigmundson i997a, b; Dreger 1998b; Kessler 1998; Preves 1998; Kipnis and Diamond 1998; Dreger 1998c. For physicians who aremov — ing toward (or embracing) the new paradigm see Schober i998; Wilson and Reiner 1998; and Phornphutkul et al. 1999. More cautiously, Meyer — Bahlburg suggests modest changes in medical practice, including giving more thought to gender assignment (an ‘‘optimal gender policy’’), elimination of nonconsensual surgery for mild degrees of genital abnormalities, and provi­sion of more support services for intersex persons and their parents. He also calls for obtaining more data on long-term outcomes (Meyer-Bahlburg 1998).

9. See comments by Chase (1998 aand 1998b). Chase has repeatedly tried to get the attention of mainstream American feminists through venues like Ms. Magazine and the academic journal Signs, but has been unable to stir their interest in the question of genital surgery on American newborns. It seems it is much more comfortable to confront the practices of other cultures than it is our own. The surgeon Justine Schober writes: ‘‘To this date, no studies of clitoral surgery address the long term results of erotic sexual sensitivity’’ (Schober 1998, p.550). Costa et al. 1997 report that of eight clitorectomized patients, two reported no orgasm during intercourse. Some who report or­gasm find it much diminished compared to before surgery. Others find it so difficult to achieve that it becomes not worth the trouble.

10. Thankfully, some physicians are open to new ideas. Mine have struck a chord with one local pediatric endocrinologist, and we have presented a case and the new thinking about how to manage intersexual births in a Grand Rounds. The surgeon discussed here did not attend, but one other surgeon did.

One local surgeon, although a colleague in the Brown Medical School, has never acknowledged my many communications. These included copies of publications such as Hermaphrodites with Attitude and Alias (a newsletter of the AIS Support Group), as well as drafts of my own writing, for which I solicited feedback. After reading an article in an in-house newsletter delineating the ‘‘standard’’ surgical approaches to intersexuality, Cheryl Chase and I wrote asking for a chance to present the emerging alternative thinking on the topic. The surgeon replied (to Chase, with only a cc rather than direct address to me) that the publication was limited to members of the Department of Pediat­rics. ‘‘We do not wish our publication to become a forum for expression of ideas, be they medical or otherwise,’’ the letter read.

11. In a much earlier study, Money reported on the effects of clitorec — tomy. He located seventeen adult women who had had such surgery as adults. Twelve of these lived as women, were older than sixteen when they discussed their erotic responses, and could report on their postoperative sensations.

Three of the twelve apparently did not cooperate (‘‘no data on orgasm were disclosed,’’ p. 294). Infour cases, ‘‘the data indicated the patient to be inexpe­rienced in orgasm.’’ In five cases, the women seemed to have experienced orgasm. The language of this report makes it unclear what the ‘‘before’’ and ‘‘after’’ surgery experiences were really like: ‘‘The point of these data on or­gasm and clitorectomy is not, however, that some clitorectomized patients did not experience orgasm. On the contrary, the point is that the capacity for orgasm proved compatible with clitorectomy and surgical feminization of the genitalia in some, if not all, of these patients’’ (p. 294). This paper, giving confusing information about twelve patients, was an important citation for those who claimed that clitoral surgery did not damage sexual function (Money 1961).

12. In this chapter I discuss only evaluations of genital surgery. Some forms of intersexuality involve chromosomal and/or hormonal changes with­out affecting visible genital components. While these conditions receive med­ical attention, especially hormonal treatments, surgery is never involved be­cause there are many fewer doubts about gender assignment. In the vast majority of these cases, the children involved have mental and emotional func­tions within a normal range. This is not to say that they encounter no difficul­ties because of their differences—only that the difficulties are surmountable. For recent literature on Turner Syndrome and other gender chromosome anomalies, see: Raboch et al. 1987; McCauley and Urquiza 1988; Sylven et al. 1993; Bender et al. 1993; Cunniff et al. 1993; Toublanc et al. 1997; and Boman etal. 1998.

13. Many of these details were conveyed to me by personal communica­tion, but Chase’s story is now widely documented. See, for example, Chase 1998a.

14. Chase’s story of doctors refusing to tell her the truth even once she had reached adulthood are repeated over and over in the stories of hundreds of adult intersexuals. These may be found scattered in newsletters, media interviews, and academic books and articles, many of which I cite in this chap­ter. The sociologist Sharon Preves has interviewed forty adult intersexuals and is beginning to publish her results. In one article she recounts Flora’s experience of visiting a genetic counselor at age twenty-four, who said, ‘‘I’m obliged to tell you that certain details of your condition have not been di­vulged to you, but I cannot tell you what they are because they would upset you too much’’ (Preves 1999, p. 37).

13. Cheryl Chase to Anne Fausto-Sterling (personal correspondence, I993).

16. Chase I998,p. 200. For more on HELP, see Harmon and Smith 1998 and visit their web site: http://www. help@jaxnet. com. Their address is P. O. Box 26292, Jacksonville, FL 32226.

17. Chase uses the following quote from an AIS support group newsletter. ‘‘Our first impression of ISNA was that they were perhaps a bit too angry and militant to gain the support of the medical profession. However, we have to say that, having read [political analyses of intersexuality by ISNA, Kessler, Fausto-Sterling, and Holmes], we feel that the feminist concepts relating to the patriarchal treatment of intersexuality are extremely interesting and do make a lot of sense’’ (Chase 1998 ,p. 200).

18. The intersexual rights movement has become international. For an example of ‘‘coming out’’ in Germany, see Tolmein and Bergling 1999. For other foreign organizations, consult the ISNA web page: http:// www. isna. org.

19. For example, the surgeon John Gearhart and colleagues published a paper in which they measured nerve responses during phallic reconstruction. In their six-case study, they were able to monitor nerve responses in the phal­lus even after surgery. They wrote: ‘‘Our study clearly shows that modern techniques of genital reconstruction allow for preservation of nerve conduc­tion in the dorsal neurovascular bundle and may permit normal sexual func­tion in adulthood’’ (Gearhart et al. 1995, p. 486). (Note that their study was done on infants, and not enough time has elapsed for adult follow-up studies.) Both in a private letter and a letter to the Journal of Urology (Chase 1995), Cheryl Chase disputed the implications of their research with case studies of her own, collected from ISNA members. She cited the absence or diminish — ment of orgasm in adults whose nervous transmission was normal. Gearhart and colleagues responded by calling for long-term follow-up studies. In an­other article, Chase points out how surgical techniques are constructed as moving targets. Criticism can always be deflected by claiming that newer techniques have solved the problem. Given that it can take decades for some of the problems to emerge, this is indeed a dilemma (Chase 1998 a; Kipnis and Diamond i998).

20. Costa et al. 1997 and Velidedeoglu et al. 1997 list clitorectomy and clitoral recession as alternatives to clitoroplasty, coldly noting that ‘‘clitorec — tomy results in loss of a sensate clitoris’’ (p. 215).

21. The cancer story is not unusual. A number of adult intersexuals re­count how, during their teen years, they believed they were dying of cancer. Moreno’s story is recounted in Moreno 1998.

22. Ibid., p. 208. This sentiment is echoed by yet another ISNA activist, Morgan Holmes, a vibrant woman in her late twenties. To prevent a miscar­riage, doctors had treated her mother with progestin, a masculinizing hor­mone, and Morgan was born with an enlarged clitoris. When she was seven, doctors performed a clitoral reduction. As with Cheryl Chase, no one talked about the operation, but Holmes remembers it. Although the surgery did not render her inorgasmic, her sexual function was severely affected. Like Chase,

Holmes chose to go public. In her Master’s thesis, analyzing her own case in the context of feminist theories on the construction and meanings of gender, she writes passionately about lost possibilities:

‘‘I like to imagine, if my body had been left intact and my clitoris had grown at the same rate as the rest of my body, what would my lesbian relationships have been like? What would my current heterosexual rela­tionship be like? What if—as a woman—I could assume a penetrative role. . . with both women and men? When the doctors initially assured my father that I would grow up to have ‘normal sexual function,’ they did not mean that they could guarantee that my amputated clitoris would be sensitive or that I would be able to achieve orgasm. . . What was being guaranteed was that I would not grow up to confuse the issue of who (man) fucks whom (woman). These possibilities. . . were negated in a reasonably simple two-hour operation. All the things I might have grown up to do, all the possibilities went down the hall with my clitoris to the pathology department. Me and my remains went to the recovery room and have not yet emerged’’ (Holmes i994,p. 53).

23. Baker 1981; Elias and Annas 1988; Goodall 1991.

24. Anonymous 1994a.

25. Anonymous 1994b.

26. The fastest way to locate these organizations and the rich support and information they provide is via the Internet. The web address is http:// www. isna. org. ISNA stands for Intersex Society of North America and their mailing address is: PO Box 3070, Ann Arbor, MI 48106-3070.

27. One woman writes: ‘‘When I discovered I had AIS the pieces finally fit together. But what fell apart was my relationship with both my family and physicians. It was not learning about chromosomes or testes that caused en­during trauma, it was discovering that I had been told lies. I avoided all medi­cal care for the next 18 years. I have severe osteoporosis as a result of a lack of medical attention. This is what lies produce’’ (Groveman 1996, p. 1,829). This issue of the Canadian Medical Association Journal contains several letters with similar sentiments written by AIS women outraged that the CMAJ had awarded second prize in a medical student essay contest on medical ethics to an essay defending the ethics of lying to AIS patients. The essay was published in an earlier issue (Natarajan 1996). For many more stories see the issues of ISNA’s (see previous note) newsletter, ‘‘Hermaphrodites with Attitude,’’ the newsletter of ALIAS, an AIS support group (email aissg@aol. com), the jour­nal Chrysalis 2:5 (fall 1997/winter 1998), and Moreno 1998. For further dis­cussion of ethical decision making, see Rossiter and Diehl 1998 and Catlin I998.

28. Meyer-Bahlburg writes: ‘‘Although current surgical procedures of cli — toral recession, if done well, appear to preserve the glans clitoris and its in­nervation, we are still in need of controlled long-term follow-up studies that assess in detail the quality of clitoral functioning in adults who have undergone such procedures [clitoral surgery] in infancy or childhood’’ (Meyer-Bahlburg i998,p. i2).

29. The most recent full-length book on the clitoris is old, by medical standards—dating from 1976 (Lowry and Lowry 1976). For a roadmap of changing conventions in clitoral representations, see Moore and Clarke 1995. A rare anatomical study of the clitoris concludes that ‘‘current anatomical descriptions of female human urethral and genital anatomy are inaccurate’’ (O’Connell et al. 1998, p. i,892). For a more complete drawing of the clitoris based on these recent findings, see Williamson and Nowak 1998. Further­more, new aspects of female genital anatomy and physiology continue to be described. See Kellogg and Parra 1991 and Ingelman-Sundberg 1997.

Perhaps the best and least known text depicting female sexual anatomy is Dickinson 1949. Dickinson is remarkable because he draws the variability, often in composite drawings, which give a vibrant sense of anatomical varia­tion. Unfortunately, his drawings have been ignored in the more standard anatomical texts. For attempts to standardize clitoral size in newborns, see Tagatz et al. 1979; Callegari et al. 1987; Oberfield et al. 1989; and Phillip et al. 1996.

30. Failure to attend to genital variability, especially in children, has made it difficult to use anatomical markers to document sexual abuse in children. Here we seem to be caught in a vicious circle. Our taboos on acknowledging infantile and immature genitalia mean that we really haven’t looked at them very systematically. This means that we have no ‘‘objective’’ way to document the very thing we fear: sexual abuse of children. It also leaves us ill-equipped to have sensible conversations with intersex children and their parents about their own anatomical differences. See, for example, McCann et al. 1990; Ber — ensonetal. 1991; Berenson et al. i992;Emans 1992; and Gardner 1992.

31. See, for example, a new, computerized image reproduced on p. 288 of Moore and Clarke 1995. This image labels only the glans and some nerves. The shaft is barely visible and the crura are unlabeled. Compare this to femi­nist publications such as Our Bodies, Ourselves. Modern anatomy CD’s for popu­lar use barely mention the clitoris and show no labeled pictures of it (see, for example, Bodyworks by Softkey).

32. Newman et al. 1992b (p. 182) write: ‘‘Long term results of opera­tions that eliminate erectile tissue are yet to be systematically evaluated.’’

33. Newman et al. (1992b) mention one of nine patients with pain with orgasm; p. 8 following clitoral recession. Randolf et al. (1981) write: ‘‘A sec­ond effort at recession is worthwhile and can be satisfactorily accomplished in spite of old scar’’ (p. 884). Lattimer (1961), in his description of the recession operation, refers to ‘‘the midline scar,’’ which ends up hidden from view in the folds of the labia majora. Allen et al. (1982) cite 4/8 clitoral recessions complaining of painful erections. Nihoul-Fekete (1981) says that clitorectomy leaves painful stumps; about recession clitoroplasty, she writes: ‘‘Clitoral sen­sitivity is retained, except in cases where postoperative necrosis resulted from excessive dissection of the vascular pedicles’’ (p. 254).

34. Nihoul-Fekete et al. 1982.

35. Allenetal. i982,p. 354.

36. Newman et al. (1992b) write that patients who underwent extensive vaginal and clitoral surgery have ‘‘sexual function ranging from satisfactory to poor’’ (p. 650). Allen et al. (1982) write that they limited vaginoplasties in infants, waiting until puberty for the full operation ‘‘rather than provoke dense scarring and vaginal stenosis following an aggressive procedure at an earlier age’’ (p. 354). Nihoul-Fekete (1981) mentions as a goal keeping the vagina free of an annular scar; on vaginoplasties: ‘‘Complications arise from poor healing with resultant stenosis of the vaginal opening’’ (p. 256). Dew — hurst and Gordon (1969) write that if the fused labial folds are divided before bowel and bladder continence is achieved, ‘‘it may be followed by imperfect healing and perhaps scarring later’’ (p. 41).

37. Nihoul-Fekete 1981.

38. A debate continues over whether it is best to perform these early in childhood or wait until adolescence or adulthood. As with hypospadias sur­gery (see previous chapter), there are many varieties of surgery for vaginal reconstruction. For a brief history of them, see Schober 1998.

39. On stenosis or vaginal narrowing: 3 out of 10 moderate to severe in- troital stenosis; 5 out of 10 moderate to severe vaginal stenosis (van der Kamp etal. 1992). Operations before 1975—of 33: 8 vaginal stenosis, 3 small vagi­nal orifice, і labial adhesions; 1 penile fibrosis. Of 25 post 1975: 3 vaginal stenosis, і labial adhesions (Lobe et al. 1987); 8 out of 14 with vaginal pullthrough type vaginoplasties developed severe stenosis (Newman et al. 1992b); 8 out of 13 early vaginoplasties: stenosis caused by scarring (p. 601) (Sotiropoulos et al. 1976). Migeon says that girls with vaginal operations ‘‘have scar tissue from surgery. They experience difficult penetration. These girls suffer’’ (in Hendricks 1993). Nihoul-Fekete et al. (1982) report 10/16 clitoral recessions in which postpubertal patients reported hypersensitivity of the clitoris.

40. Bailezetal. i992,p. 681.

41. Colapinto 1997.

42. One recent evaluation of the psychological health of intersex children found: ‘‘dilating the vagina at a younger age appeared to lead to severe psycho­logical problems because it was experienced as a violation of the body integ­rity’’ (Slijper et al. i998)p. 132.

43. Colapinto 1997; Money and Lamacz 1987.

44. Bailezetal. 1992.

45. Newmanetal. 1992a, p. 651. The data from Allen et al.—thatseven of their eight patients required more than one surgery to complete clitoro — plasty—suggests that multiple operations may be the rule rather than the exception (Allen et al. 1982). Innes-Williams i98i, p. 243.

46. Additional data on multiple surgeries follow: Randolf et al. 1981: 8 out of 37 required second operations to make clitoral recession ‘‘work.’’ Lobe et al. 1987: 13 out of 58 patients required more than two operations; it seems likely from their discussion that many more of the 58 required two operations, but the data are not given. Allen et al (1982): 7 out of 8 clitoroplasties needed additional surgery. Van der Kamp et al. (1982): 8 out of io patients required two or more surgeries. Sotiropoulos et al. 1976: 8 out of 13 early vaginoplas­ties required second operations. Jones and Wilkins (1961): 40 percent of pa­tients required second surgery with vaginoplasties. Nihoul-Fekete et al. (1982) report 33 percent of their early vaginoplasties required later additional surgery. Newman et al. (1992a): 2 out of 9 required second recession opera­tions; 1/9 required second vaginoplasty. Azziz et al. (1986): 30/78 repeat (second and third times) surgeries for vaginoplasties; success ofvaginoplasties was only 34.3 percent when done on children younger than four years ofage. Innes-Williams (1981) writing about operations for hypospadias: recom­mends for intersexes two operations and says that poor technique or poor wound healing can mean further (third or more) surgery. See also Alizai et al. 1999.

The number of surgeries can rise to as high as 20. In one study of 73 hypo­spadias patients the mean number of operations was 3 . 2 , while the range ran from i to 20. See reports by Mureau, Slijperetal. 1995a, 1995b, 1995c.

47. Mulaikal et al. 1987.

48. The psychological results of hypospadias surgery may differ in differ­ent cultures. A series of studies done in the Netherlands, for example, where male circumcision is uncommon, found that dissatisfaction with genital ap­pearance resulted in part from the circumcised appearance following hypo­spadias surgery (Mureau, Slijperetal. 1995a, 1995b, 1995c; Mureau 1997; Mureau et al. 1997). For an earlier study, see Eberle et al. (1993), who found persistent cases of sexual ambiguity (seen as a bad thing) in ii percent of their hypospadias patients. Duckett found ‘‘this study most disturbing for those of us who offer an optimistic outlook for our patients with hypospadias’’ (Duck­ett i993, p. i,477).

49. Miller and Grant i997. For more on the effects of hypospadias, see Kessler i998, pp. 70—73.

50. Sandberg and Meyer-Bahlburg i995. See also Berg and Berg ^83, who report increased uncertainty about gender identity and masculinity but no increase in homosexuality among men with hypospadias.

51. Slijperetal. i998,p. 127.

52. Ibid.

53. Harmon-Smith, personal communication. For more on HELP and other support groups, consult the ISNA Web page: http://www. isna. org.

54. Harmon-Smith 1998. The full commandments are:

1) DO NOT tell the family to not name ‘‘the child’’! Doing so only isolates them, and makes them begin to see their baby as an ‘‘abnormality.’’

2) DO encourage the family to call their child by a nickname (Honey, Cutie, Sweetie, or even ‘‘little one’’) or by a non-gender-specific name.

3) DO NOT refer to the patient as ‘‘the child.’’ Doing so makes parents begin to see their child as an object, not a person.

4) DO call the patient by nickname/name chosen by the parents. It may be uncomfortable at first but will help the parents greatly. Example: ‘‘How is your little sweetie doing today?’’

5) DO NOT isolate the patient in a NICU. This scares the parents and makes them feel something is very wrong with their child. It isolates the family and prevents siblings, aunts, uncles and even grandparents from visiting and it starts a process within the family of treating the new mem­ber differently.

6) DO allow the patient to stay on a regular ward. Admit patients to the children’s wing, perhaps in a single room. Then visitors are allowed, and bonding within the family can begin.

7) DO connect the family with an information or support group. There are many available: National Organization for Rare Disorders (NORD); Parent to Parent; HELP; AIS support group; Intersex Society of North America; even March of Dimes or Easter Seals.

8) DO NOT isolate the family from information or support. Do not assume they will not understand or will be more upset if they learn about other disorders or related problems. Let the parents decide what informa­tion they want or need. Encourage them to seek out who can give them information and share experiences.

9) DO encourage the family to see a counselor or therapist. Do not only refer them to a genetic counselor; they will need emotional sup­port as well as genetic information. Refer them to a family counselor, therapist or social worker familiar with family crisis intervention/ therapy.

10) DON OT make drastic decisions in the first year. The parents need time to adjust to this individual child. They will need to understand the condition and what their specific child needs. Allow them time to get over being presented with new information and ideas. Let them understand that their child is not a condition that must conform to a set schedule but

an individual. DO NOT schedule the first surgery before the patient even

leaves the hospital. This will foster fear in the parents that this is life

threatening and they have an abnormal or damaged child.

yy. Kessler i998,p. 129.

y6. Young 1937, p. iy4. For a more recent example, see several cases of parental refusal of sex reassignment following traumatic injury to their sons’ penises in Gilbert et al. 1993.

У7. Young I937, p. iy8.

y8. Recently academics have begun to analyze the phenomenon of dis­playing extraordinary bodies as a form of public entertainment. For an entree into this literature, see Thomson 1996.

y9. Kessler 1990.

60. Young i937,p. 146.

61. Dewhurst and Gordon 1963^.77.

62. Randolfetal. i98i, p.88y.

63. Van der Kamp et al. i992.

64. Bailezetal. i992,p. 886. ‘‘A number of mothers reported their hus­bands were actually opposed to surgery,’’ and they cite one patient whose sur­gery was postponed because the family wanted the child to participate in the decision-making process (Hendricks i993). Migeon reports on others who stop taking medication that prevents virilization. Jones and Wilkins (i96i) report a patient who accepted hysterectomy and mastectomy but refused geni­tal operations, even though he had to pee sitting down. Azziz et al. (i986) report on sixteen patients requiring repeat operations to achieve goal of com­fortable intercourse, five never followed through on having them. Lubs et al. (i9y9) talk of a sixteen-year-old patient with genital abnormalities: ‘‘The family felt she should not be subject to further examination and would permit no studies to be carried out’’ (p. i, m3). Van Seters and Slob (i988) describe a case of micropenis in which the father refused surgery until the boy was old enough to decide for himself. Hurtig et al. ^983) discuss noncompliance with taking antimasculinizing drugs in two of four patients they studied. Hampson (i9yy) mentions a few parents who have refused recommendations of sex change surgery, ‘‘assured by their own thoroughgoing conviction of the boyness of their son or the girlness of their daughter’’ (p. 267). Beheshti et al. (i983 ) mention two cases in which parents refused gender reassignment.

6y. Van Seters and Slob (i988). For more on the ability of children with micropenises, raised as males to adjust to the male sexual role, see Reilly and Woodhousei989.

66. Hampson and Hampson i96i, pp. i,428—29; emphasis added.

67. Because of the small sample size, these numbers do not reach statisti­cal significance, it could be random chance that the numbers came out this way. I expand upon my prejudice to the contrary in this paragraph.

68. Actually, this moment is already here, as the agendas of ISNA and other organizations attest.

69. Kessler i998,p. 131.

70. Ibid., p. 40

71. Despite medical skepticism, ISNA’s message is making inroads. A re­cent article from a nursing journal discussed ISNA’s viewpoint and noted that ‘‘it is important to help parents focus on their infant as a whole rather than on the infant’s condition. The nurse can emphasize a child’s features that are unrelated to gender, such as ‘what beautiful eyes the baby has,’ or ‘your baby has a nose just like daddy’s’’’ (Parker i998,p. 22). See also the editorial in the same issue (Haller 1998).

72. There is a significant and fascinating literature on transsexuality. See, for instance, Hausman 1992 and 1995; Bloom 1994; Bollin 1994; and Devor

i997.

73. Major work on transgender theory and practice includes Feinberg 1996 and 1998; Ekins and King 1997; Bornstein 1994 and Atkins 1998. Also, browse issues of the journal Chrysalis: The Journal of Transgressive Gender Iden­tities.

74. Bolin I994, pp. 461,473.

75. Ibid.,p. 484.

76. Rothblatt i995,p. 115.

77. Lorber I993,p.571.

78. See also the discussion in chapter i. Also, Herdt i994a, b; Besnier 1994; Roscoe i99i and i994; Diedrich i994; and Snarch i992.

79. An ascetic sect, the Hijras are invested with the divine powers of the goddess; they dance and perform at the birth of male children and at mar­riages, and also serve the goddess at her temple (Nanda i986, ^89, and i994).

80. Without the enzyme, the body cannot transform the hormone testos­terone into a related form—dihydrotestosterone (DHT). In the embryo, DHT mediates the formation of the male external genitalia.

81. For a thorough recent review of the biology, see Quigley et al. i995 and Griffin and Wilson ^89.

82. This form of androgen insensitivity is often misdiagnosed, and irrepa­rable surgery, such as removal of the testes, is performed. When the potential difficulties go “unmanaged’’ until puberty, more satisfactory options are avail­able for an affected individual. See the discussion on p. i,9 29 of Griffin and Wilson i989, and a case discussed in Holmes et al. i992.

In Fausto-Sterling i992, I discuss the appropriation of events in the small villages of the Dominican Republic for an argument raging in the United States over whether innate biology or sex of rearing determines gender role and preference. The debate parallels the Joan/John dispute and the study of gender role acquisition in CAH girls discussed in chapter 3.

83. Herdt and Davidson 1988; Herdt i99oband 1994a, b.

84. Herdt i994,p. 429.

83. Kessler i998,p. 90.

86. Press 1998.

87. Rubin i984,p. 282.

8 8. Kennedy and Davis 1993.

89. Feinberg i996,p. 123.

90. For a complete statement of the International Bill of Gender Rights, see pp. i63—169 of Feinberg i996.

91. For a thorough and thoughtful treatment of the legal issues (which by extrapolation might apply to intersexuals), see Case i993. For a discussion of how legal decisions construct the heterosexual and homosexual subject, see Halley i99i, i993, and i994.

92. In Norton i996,pp. i87—88.

93. As sex reassignment surgery became more common in the i93os, doctors worried about their personal liability. Even though physicians ob­tained parental approval, could a child—upon reaching the age of majority— sue the surgeon ‘‘for charges ranging from malpractice to assault and battery or even mayhem’’? Despite ‘‘this disagreeable quirk in the law,’’ the worried physician writing this passage felt he ought not shrink from ‘‘handling these unfortunate children… in whatever way seems. . . to be most suitable and humane’’ (Gross and Meeker i933,p. 32i).

In i937, Dr. E. C. Hamblen, reiterating the fear of lawsuit, sought the aid of a law clinic at Duke University. One suggested solution, which never saw the light of day, was to set up state boards or commissions ‘‘on sex assignment or reassignment, comparable to boards of eugenics which authorize steriliza­tion.’’ Hamblen hoped such action could protect a physician whose position he feared ‘‘might be precarious, indeed, if legal action subsequently resulted in a jury trial’’ (Hamblen i937, p. i,24o). After this early flurry of self­concern, the medical literature falls silent on the question of the patient’s right to sue. Perhaps doctors have relied both on their near certainty that current medical approaches to intersexuality are both morally and medically correct and on the realization that the vast majority of their patients would never choose to go public about such intimate matters. In the post—Lorena Bobbit era, however, it seems only a matter oftime until some medical profes­sional confronts the civil claims of a genitally altered intersexual.

94. O’Donovan i983. For an up-to-date review of the legal status of the intersexual, see Greenberg i999.

93. O’Donovan i983, p. i3; Ormrod i992.

96. Edwards i939,p. ii8.

97. Halley i99i.

98. Ten Berge i96o, p. ii8.

99. See de la Chapelle 1986; Ferguson-Smith et al. 1992; Holden 1992; Kolata 1992; Serrat and Garcia de Herreros 1993; Unsigned 1993.

100. I never would have guessed, when I first drafted this chapter in 1993, that in 1998 homosexual marriages would be on the ballots in two states. Although it lost in both cases, clearly the issue is now open to discussion. I believe it is a matter of time before the debate will be joined again, with different results.

101. Rhode Island repealed its antisodomy law in 1998, the same year that a similar law was found unconstitutional in the state of Georgia.

102. Reilly and Woodhouse 1989^. 371; see also Woodhouse 1994.