Those who defend current approaches to the management of intersexuality can, at best, offer a weak case for continuing the status quo. Many patients are scarred—both psychologically and physically—by a process heavy on sur-
table 4. з Psychological Outcomes of Children Raised as Males with Unusual Genitalia
|
DEVELOPMENTAL PATTERN (sample size) |
CHANGE IN assigned sex |
MEDICAL INTERVENTION |
methods of assessment |
OUTCOME |
comments |
source |
|
XX intersex (i) |
None; raised as male |
Age ii : removal of i ovary; age 24: ovarian biopsy |
Physical and hormonal only |
A married male with a satisfactory sex life |
Never told about his actual physical condition |
a |
|
Small penis, bifid scrotum, urinate at base of phallus; at puberty breast growth and identification of uterus, oviducts, and ovaries |
Raised as male; reassigned female as teenager |
Vaginal reconstruction at age 17; no clitoral surgery |
Physical, hormonal, psychiatric interviews, and MMPI, Rorschach test |
Married at age 20 and hoping to have child |
As a child liked being a boy; received considerable sex ed from parents; mother encouraged her to be secret about genitals because of anatomical difference |
b |
|
Sexual precocity in genetic, gonadal, and hormonal male ( i ) |
None; raised as male |
Extensive family counseling |
IQ; standard psychological tests; interviews |
“Thoroughly adequate psychological adjustment’’ (p. ij) |
Healthy family life |
c |
|
XX intersex; small hy- pospadic phallus; fused, empty labioscrotum ( i ) |
None; raised as male |
As teenager, breasts and female internal organs removed; hormone treatments; at age 23 plastic surgery on penis |
Extensive interviews |
Married male; ‘‘to the world at large. . . he passed as an ordinary male college graduate—one of the more stable and well — adjusted’’ (p. 317) |
Only case study in a paper that summarizes a large number of studies but gives few specific details |
d |
|
САН; small phallus with urethra running through it (i) |
None; raised as male; hematuria at age 18 warranted medical workup |
At age 18, removal of uterus and ovaries; hormonal treatment |
Clinical report |
|
CAH; penile urethra; phallus у cm long at age 2i (i) |
None; raised as male; cyclic urethral bleeding |
None |
Physical only |
|
CAH; pubic and axillary hair since age у; menstruation at age 2 6; micropenis; penile urethra (i) |
None; at age ЗУ expressed wish to be a woman |
Adrenal surgery, which resulted in death of patient |
Physical and casual observation |
|
Same physical development (i) (Younger brother of previous case) |
None |
Hormone treatment starting at age 2 у (refused surgery due to death of brother) |
Physical and casual observation |
|
CAH with microphallus (2) |
None; raised as males |
Ovaries, uterus removed at ages 1 2 and 31, respectively |
Psychological, via interview |
|
“Attending college, majoring in music, and was interested in sports”; had sexual contacts with women (P — iJ7) |
“At age і о the patient no — e ticed that his external genitalia were smaller than those of other boys his age, and, from that time on, took care not to expose himself before his schoolmates” (p. i^6) |
|
A married male |
N о data given on psycho — f logical status |
|
Normal intelligence; served in Army |
During adolescence, g attracted to male |
|
during WWII |
companions |
|
Married at age г г; had sexual intercourse regularly |
Began menstruation at 2 2 h |
|
Both married; one with child via donor insemination; rate sex lives as good |
Adapted to sexual і activity other than vaginal intercourse ^ |
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Participated in sports о
with other boys; “social adaptation adequate throughout childhood” (p. 663)
Patient managed to con — p ceal from his family his need to sit down to urinate
“4 ambivalent with All ambivalent cases q
respect to gender reared as girls role” (p. 236)
Psychological exam — No details of life outcome r iners recommended against sex change
(continued)
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gical prowess and light on explanation, psychological support, and full disclosure. We stand now at a fork in the road. To the ri ght we can walk toward reaffirmation of the naturalness of the number 2 and continue to develop new medical technology, including gene ‘‘therapy’’ and new prenatal interventions to ensure the birth of only two sexes. To the left, we can hike up the hill of natural and cultural variability. Traditionally, in European and American culture we have defined two genders, each with a range of permissible behaviors; but things have begun to change. There are househusbands and women fighter pilots. There are feminine lesbians and gay men both buff and butch. Male to female and female to male transsexuals render the sex/gender divide virtually unintelligible.
All of which brings me back to the five sexes. I imagine a future in which our knowledge of the body has led to resistance against medical surveillance,68 in which medical science has been placed at the service of gender variability, and genders have multiplied beyond currently fathomable limits. Suzanne Kessler suggests that ‘‘gender variability can… be seen. . . in a new way— as an expansion of what is meant by male and female.’’69 Ultimately, perhaps, concepts of masculinity and femininity might overlap so completely as to render the very notion of gender difference irrelevant.
In the future, the hierarchical divisions between patient and doctor, parent and child, male and female, heterosexual and homosexual will dissolve. The critical voices of people discussed in this chapter all point to cracks in the monolith of current medical writings and practice. It is possible to envision a new ethic of medical treatment, one that permits ambiguity to thrive, rooted in a culture that has moved beyond gender hierarchies. In my utopia, an intersexual’s major medical concerns would be the potentially life-threatening conditions that sometimes accompany intersex development, such as salt imbalance due to adrenal malfunction, higher frequencies of gonadal tumors, and hernias. Medical intervention aimed at synchronizing body image and gender identity would only rarely occur before the age of reason. Such technological intervention would be a cooperative venture among physician, patient, and gender advisers. As Kessler has noted, the unusual genitalia of intersexu — als could be considered to be ‘‘intact’’ rather than ‘‘deformed’’; surgery, seen now as a creative gesture (surgeons ‘‘create’’ a vagina), might be seen as destructive (tissue is destroyed and removed) and thus necessary only when life is at stake.70
Accepted treatment approaches damage both mind and body. And clearly, it is possible for healthy adults to emerge from a childhood in which genital anatomy does not completely match sex of rearing. But still, the good doctors
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XY intersex; small |
None; raised as |
As a married adult, |
|
penis and vagina (i) |
female |
penis removed and vagina dilated |
|
XY intersex; mal |
None; raised as |
At age 21 testes removed, |
|
formed external |
female |
vagina enlarged, estrogen |
|
genitalia; no breast development (i) |
treated |
|
|
Testicular failure; |
Sex change |
|
|
ambiguous but femi |
from female to |
|
|
nized genitalia (з) |
male at ages 20-33 |
|
|
Normal male with |
Sex reassigned |
Surgery to correct |
|
severe perineal hypospadias, raised as female (i) |
at 14 |
hypospadias |
|
CAH females (7) |
None; raised as female |
None |
|
None |
|
Unknown |
|
Conversations with physician |
|
Psychological tests and interviews |
|
Psychological and interviews |
Happily married but d
infertile
“ Quite well adjusted in e
her role as a woman”
(P — 43)
2: no information; 1: Calls for a “somewhat less f
“patient most sat — rigid attitude” about when
isfied” (p.1,214) to do surgery (p. 1,216)
Successful adjustment “The Johns Hopkins team g
following a period of… [has] not provided con — several months vincing evidence” for view
that early sex change is imperative (p. 1,217) [3]
TABLE 4.4 (Continued)
|
DEVELOPMENTAL PATTERN CHANGE IN MEDICAL METHODS OF (sample size) assigned sex intervention assessment outcome comments source
|
Hypospadias; raised Changed from Several surgeries at pa — as female (i) female to male tient’s request to repair
at age і з hypospadias
|
Hypospadias; raised as female (i) |
Changed from female to male at age і з |
Surgical repair of hypospadias and exposure of hooded penis |
|
Intersex; raised as female (i) |
None |
Surgery at i 8 to open vagina |
|
Intersex, raised as male (i) |
None |
Repair of hypospadias at age 29 |
Wishes he could have inter — 1 course and biological children, but resigned; “I have a full and for the most part happy life” (p. 1,2^6)
Patient anxious to make the m change, “had his own ideas. . . even to selection of a name and a decidedly masculine program of activities” (p. 490)
Early in her life the patient n was told by her mother that “she was different from other boys and girls and that she should not let others see her genitalia” (p. 431)
Small, curved penis “did о
not trouble the patient before he got married”
(p. 332), and he only sought help because he could not ejaculate inside the vagina and he wanted to have children
(continued)
 |
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TABLE 4.4 (Continued)
|
If notspecified, surgeryoccurredat thetimeofchange in sexof rearing. * Alsolisted intable 4.3. a. Nogalesetal. 19^6. b. Hampson and Money 19^^.
c. Lubsetal. 19^9. d. Ten Berge i960. e. Jones 19^7. f. DewhurstandGordon 1963. g. Berg 1963. h. Money 19^^. i. Money, Hampson, et al. 19^^. j. Witschi andMengert 1942. k. Laycock and Davies 19^3. l. Armstrong 1966. m. BrownandFryer 19^7. n. Brewer etal. 19^2. o. Zachariae 19^^. p. Jones and Wilkins 1961. q. Gooren and Cohen-Kettenis 1991.
are skeptical.71 So too are many parents and potential parents. It is impossible not to personalize the argument. What if you had an intersexual child? Could you and your child become pioneers in a new management strategy? Where, in addition to the new intersexual rights activists, might you look for advice and inspiration?
The history of transsexualism offers food for thought. In European and American culture we understand transsexuals to be individuals who have been born with ‘‘good’’ male or ‘‘good’’ female bodies. Psychologically, however, they envision themselves as members of the ‘‘opposite’’ sex. A transsexual’s drive to have his/her body conform with his/her psyche is so strong that many seek medical aid to transform their bodies hormonally and ultimately surgically, by removal of their gonads and transformation of their external genitalia. The demands of self-identified transsexuals have contributed to changing medical practices, forcing recognition and naming of the phenomenon. Just as the idea that homosexuality is an inborn, stable trait did not emerge until the end of the nineteenth century, the transsexual did not fully emerge as a special type of person until the middle of the twentieth. Winning the right to surgical and legal sex changes, however, exacted a price: the reinforcement of a two-gender system.72 By requesting surgery to make their bodies match their gender, transsexuals enacted the logical extreme of the medical profession’s philosophy that within an individual’s body, sex, and gender must conform. Indeed, transsexuals had little choice but to view themselves within this framework if they wanted to obtain surgical help. To avoid creating a ‘‘lesbian’’ marriage, physicians in gender clinics demanded that married transsexuals divorce before their surgery. Afterwards, they could legally change their birth certificates to reflect their new status.
Within the past ten to twenty years, however, the edifice of transsexual dualism has developed large cracks. Some transsexual organizations have begun to support the concept of transgenderism, which constitutes a more radical re-visioning of sex and gender.73 Whereas traditional transsexuals might describe a male transvestite—a man dressing in women’s clothing—as a transsexual on the road to becoming a complete female, transgenderists accept ‘‘kinship among those with gender-variant identities. Transgenderism supplants the dichotomy of transsexual and transvestite with a concept of continuity.’’ Earlier generations of transsexuals did not want to depart from gender norms, but rather to blend totally into their new gender role. Today, however, many argue that they need to come out as transsexuals, permanently assuming a transsexual identity that is neither male nor female in the traditional sense.74
Within the transgender community (which has its own political organiza
tions and even its own electronic bulletin board on the Internet), gender variations abound. Some choose to become women while keeping their male genitals intact. Many who have undergone surgical transformation have taken up homosexual roles. For example, a male-to-female transsexual may come out as a lesbian (or a female-to-male as a gay male). Consider Jane, born a physiological male, now in her late thirties, living with her wife (whom she married when her name was still John). Jane takes hormones to feminize herself, but they have not yet interfered with her ability to have erections and intercourse as a man:
From her perspective, Jane has a lesbian relationship with her wife (Mary). Yet she also uses her penis for pleasure. Mary does not identify herself as a lesbian, although she maintains love and attraction for Jane, whom she regards as the same person she fell in love with although this person has changed physically. Mary regards herself as heterosexual. . . although she defines sexual intimacy with her spouse Jane as somewhere between lesbian and heterosexual.75
Does acceptance of gender variation mean the concept of gender would disappear entirely? Not necessarily. The transgender theorist Martine Rothblatt proposes a chromatic system of gender that would differentiate among hundreds of different personality types. The permutations of her suggested seven levels each of aggression, nurturance, and eroticism could lead to 343 (7 x 7 x 7) shades of gender. A person with a mauve gender, for example, would be ‘‘a low-intensity nurturing person with a fair amount of eroticism but not much aggressiveness.’’76 Some might find Rothblatt’s system silly or unnecessarily complex. But her point is serious and begins to suggest ways we might raise intersex children in a culture that recognizes gender variation.
Is it so unreasonable to ask that we focus more clearly on variability and pay less attention to gender conformity? The problem with gender, as we now have it, is the violence—both real and metaphorical—we do by generalizing. No woman or man fits the universal gender stereotype. ‘‘It might be more useful,’’writes the sociologist Judith Lorber, ‘‘. . . to group patterns ofbehav — ior and only then look for identifying markers of the people likely to enact such behaviors.’’77
Were we in Europe and America to move to a multiple sex and gender role system (as it seems we might be doing), we would not be cultural pioneers. Several Native American cultures, for example, define a third gender, which may include people whom we would label as homosexual, transsexual, or intersexual but also people we would label as male or female.78 Anthropologists have described other groups, such as the Hijras of India, that contain individuals whom we in the West would label intersexes, transsexuals, effeminate men, and eunuchs. As with the varied Native American categories, the Hijras vary in their origins and gender characteristics.79 Anthropologists debate about how to interpret Native American gender systems. What is important, however, is that the existence of other systems suggests that ours is not inevitable.
I do not mean to romanticize other gender systems; they provide no guarantee of social equality. In several small villages in the Dominican Republic and among the Sambia, a people residing in the highlands of Papua, New Guinea, a genetic mutation causing a deficiency in the enzyme 5-a-reductase occurs with fairly high frequency.80 At birth, XY children with 5-a-reductase deficiency have a tiny penis or clitoris, undescended testes, and a divided scrotum. They can be mistaken for girls, or their ambiguity may be noticed. In adolescence, however, naturally produced testosterone causes the penises of XY teenagers deficient in 5-a-reductase to grow; their testes descend, their vaginal lips fuse to form a scrotum, their bodies become hairy, bearded, and musclebound.81
And in both the Dominican Republic and New Guinea, DHT-deficient children—who in the United States are generally operated on immediately— are recognized as a third sex.82 The Dominicans call itguevedoche, or ‘‘penis at twelve,’’ while the Sambians use the word kwolu-aatmwol, which suggests a person’s transformation ‘‘into a male thing.’’83 In both cultures, the DHT — deficient child experiences ambivalent sex-role socialization. And in adulthood s/he most commonly—but not necessarily with complete success— self-identifies as a male. The anthropologist Gil Herdt writes that, at puberty, ‘‘the transformation may be from female—possibly ambiguously reared— to male-aspiring third sex, who is, in certain social scenes, categorized with adult males.’’84
While these cultures know that sometimes a third type of child is born, they nevertheless recognize only two gender roles. Herdt argues that the strong preference in these cultures for maleness, and the positions offreedom and power that males hold, make it easy to understand why in adulthood the kwolu-aatmwol and the guevedoche most frequently chose the male over the female role. Although Herdt’s work provides us with a perspective outside our own cultural framework, only further studies will clarify how members of a third sex manage in cultures that acknowledge three categories of body but offer only a two-gender system.