If there has been no prenatal ‘‘fix’’ and an intersex child is born, doctors must decide, as they would put it, nature’s intention. Was the newborn infant ‘‘supposed’’ to have been a boy or a girl? Dr. Patricia Donahoe, Professor of Surgery at Harvard Medical School and a highly accomplished researcher in the fields of embryology and surgery, has developed a rapid procedure for choosing an ambiguous newborn’s gender assignment. First she ascertains whether the newborn has two X chromosomes (is chromatin-positive) and then whether the child has symmetrically placed gonads. She places a chromatin-positive child with symmetrical gonads in the female pseudo-hermaphrodite box. In contrast, she is likely to classify an XX child with asymmetrical gonads as a true hermaphrodite, since the asymmetry most commonly reflects the presence of a testis on one side and an ovary on the other.
Children with one X chromosome (chromatin-negative) can also be divided into two groups: one with symmetrical and one with asymmetrical
gonads. Babies with gonadal symmetry who are chromatin-negative fall into the male pseudo-hermaphrodite cubbyhole, while gonadally asymmetrical chromatin-negatives receive the label mixed-gonadal dysgenesis, a catchall category containing individuals whose potentially male gonads have some form of abnormal development.45 This stepwise decision tree, which uses the permutations derived from the symmetry of gonads and the presence or absence of a second X, enables the physician to categorize the intersexual newborn fast. A more thorough and accurate assessment of the individual’s specific situation can take weeks or months.
Enough is known about each of the four categories (true, male pseudo, female pseudo, and gonadal dysgenesis) to predict with considerable, although not complete, accuracy how the genitalia will develop as the child grows and whether the child will develop masculine or feminine traits at puberty. Given such knowledge, medical managers employ the following rule: ‘‘Genetic females should always be raised as females, preserving reproductive potential, regardless ofhow severely the patients are virilized. In the genetic male, however, the gender of assignment is based on the infant’s anatomy, predominantly the size of the phallus.’’46
Doctors insist on two functional assessments of the adequacy of phallus size. Young boys should be able to pee standing up and thus to ‘‘feel normal’’ during little-boy peeing contests; adult men, meanwhile, need a penis big enough for vaginal penetration during sexual intercourse.47 How big must the organ be to fulfill these central functions and thus fit the definition of penis? In one study of ioo newborn males, penises ranged in length from 2.9 to 4.5 centimeters (1.25 to 1.75 inches).48 Donahoe and her co-workers express concern about a phallus of 2.0 centimeters, while one less than i.5 centimeters long and 0.7 centimeters wide results in a female gender assignment.49
In fact, doctors are not sure what to count as a normal penis. In an ‘‘ideal’’ penis, for example, the urethra opens at the very tip of the glans. Suburethral openings are often thought of as a pathology designated with the medical term hypospadias. In a recent study, however, a group of urologists examined the location of the urethral opening in 500 men hospitalized for problems unrelated to hypospadias. Judged by the ideal penis, only 55 percent of the men were normal.50 The rest had varying degrees of mild hypospadias, in which the urethra opened near, but not at, the penis tip. Many never knew that they had been urinating from the wrong place their entire lives! The authors of this study conclude:
Pediatric urologists should be aware of the observed ‘‘normal distribution” of meatal [urethral] positions. . . since the aim of reconstructive
surgery should be to restore the individual to normal. However, pure esthetic surgery would try to surpass the normal. . . this is the case in many patients with hypospadias in whom the surgeon attempts to place the meatus in a position where it would not be found in 45% of so-called normal men.51
The worries in male gender choice are more social than medical.52 Physical health is usually not an issue, although some intersexed babies might have problems with urinary tract infection, which, if very severe, can lead to kidney damage. Rather, early genital surgery has a set of psychological goals. Can the surgery convince parents, caretakers, and peers—and, through them, the child him/herself—that the intersexual is really a male? Most intersexual males are infertile, so what counts especially is how the penis functions in social interactions—whether it ‘‘looks right’’ to other boys, whether it can ‘‘perform satisfactorily’’ in intercourse. It is not what the sex organ does for the body to which it is attached that defines the body as male. It is what it does vis-a-vis other bodies.53 Even our ideas about how large a baby’s penis needs to be to guarantee maleness are fairly arbitrary. Perhaps unintentionally, Do — nahoe drove home the social nature of the decision-making process when she commented that ‘‘phallus size at birth has not been reliably correlated with size and function at puberty.’’54 Thus, doctors may choose to remove a small penis at birth and create a girl child, even though that penis may have grown to ‘‘normal’’ size at puberty.55
Deciding whether to call a child a boy or a girl, then, employs social definitions of the essential components of gender. Such definitions, as the social psychologist Suzanne Kessler observes in her book Lessons from the Intersexed, are primarily cultural, not biological.56 Consider, for instance, problems caused by introducing European and American medical approaches into cultures with different systems of gender. A group of physicians from Saudi Arabia recently reported on several cases of XX intersex children with congenital adrenal hyperplasia (CAH), a genetically inherited malfunction of the enzymes that aid in making steroid hormones. Despite having two X chromosomes, some CAH children are born with highly masculinized genitalia and are initially identified as males. In the United States and Europe such children, because they have the potential to bear children later in life, are usually raised as girls. Saudi doctors trained in this European tradition recommended such a course of action to the Saudi parents of CAH XX children. A number of parents, however, refused to accept the recommendation that their child, initially identified as a son, be raised instead as a daughter. Nor would they accept feminizing surgery for their child. As the reporting physicians write, ‘‘female
|
|
figure з.4: Phall-o-Metrics. The ruler numbers indicate centimeters (not to scale). (Source: Alyce Santoro, for the author) upbringing was resisted on social grounds. . . . This was essentially an expression of local community attitudes with. . . the preference for male off-
”57
spring.
If labeling intersex children as boys is tightly linked to cultural conceptions of the maleness and ‘‘proper penile function,’’ labeling such children as girls is a process even more tangled in social definitions of gender. Congenital adrenal hyperplasia (CAH) is one of the most common causes of intersexuality in XX children. CAH kids have the potential to become fertile females in adulthood. Doctors often follow Donahoe’s rule that reproductive function be preserved, although Kessler reports one case of a physician choosing to reassign as male a potentially reproductive genetic female infant rather than remove a well- formed penis.58 In principle, however, the size rule predominates in male assignment. One reason is purely technical. Surgeons aren’t very good at creating the big, strong penis they require men to have. If making a boy is hard, making a girl, the medical literature implies, is easy. Females don’t need anything built; they just need excess maleness subtracted. As one surgeon well known in this field quipped, ‘‘you can make a hole but you can’t build a pole.’’59
As a teaching tool in their struggle to change the medical practice of infant genital surgery, members of the Intersexual Rights Movement have designed a ‘‘phall-o-meter’’ (shown in figure з.4), a small ruler that depicts the permis-
|
TABLE 3.3 Recent History of Clitoral Surgery
Source: Extractedfrom data foundinRosenwald etal. 19^8; Money 1961; Randolf andHung 1970; Randolf et al. 1981; Donahoe and Hendren 1984; Hampson 19^^; Hampson and Money i955; Gross et al. 1966; Lattimer 1961; Mininberg 1982; Rajfer et al. 1982; van der Kamp et al. 1992; Ehrhardt etal. i968;Allen etal. i982;Azzizetal. i986;Newmanetal. i992b;Mulaikal etal. 1987; Kumar etal. 1974; and Hendren and Crawford 1969. a. May include previously reported data. |
sible ranges of phallus size for males and females at birth. It provides a graphic summary of the reasoning behind the decision-making process for assigning gender. If the clitoris is ‘‘too big’’ to belong to a girl, doctors will want to downsize it,60 but in contrast to the penis, doctors have rarely used precise clitoral measurements in deciding the gender of a newborn child. Such measurements, however, do exist. Since 1980, we have known that the average clitoral size of newborn girls is 0.345 centimeters.61 More recent studies show that clitoral length at birth ranges from 0.2 to 0.85 centimeters.62 One surgeon prominent in the field of sex reassignment surgery, when interviewed in 1994, seemed unaware that such information existed. He also thought the measurements irrelevant, arguing that for females ‘‘overall appearance’’ counts rather than size.63 Thus, despite published medical information showing a range of clitoral size at birth, doctors may use only their personal impressions to decide that a baby’s clitoris is ‘‘too big’’ to belong to a girl and must be downsized, even in cases where the child is not intersexual by any definition.64 Physicians’ ideas about the appropriate size and look of female genitals thus sometimes leads to unnecessary and sexually damaging genital surgery.65
Consider, for example, infants whose genitalia lie in that phallic limbo: bigger than 0.85 but smaller than 2.0 centimeters long (see figure 3.4). A systematic review of the clinical literature on clitoral surgery from 1950 to the present reveals that although doctors have been consistent over the years in assigning such infants to become female, they have radically shifted their
ideas about female sexuality and, consequently, their notions of appropriate surgical treatment for female-intersex babies (see table 3.3). In the early days of surgical treatment, doctors performed complete clitorectomies on children assigned to be females (the procedure is illustrated in figure 3. $), reasoning that female orgasm was vaginal rather than clitoral.66
During the 1960s, physicians slowly began to acknowledge the clitoral basis of female orgasm, although even today some surgeons maintain that the clitoris is unnecessary for female orgasm.67 In the sixties, then, physicians turned to the procedures still used in some form today. In the operation known as a clitoral reduction, the surgeon cuts the shaft of the elongated phallus and sews the glans plus preserved nerves back onto the stump (figure 3.6). In the less frequently used clitoral recession, the surgeon hides the clitoral shaft (referred to by one group of surgeons as ‘‘the offending shaft’’)68 under a fold of skin so that only the glans remains visible (figure 3.7). Depending upon their anatomy at birth, some female-assigned children face additional surgery: vaginal construction or expansion and labio-scrotal reduction.
Intersex children assigned to become boys also face extensive surgery. There are over 300 surgical ‘‘treatments’’ described in the medical literature for hypospadias, the opening of the urethra at some point along the shaft of
|
figure 3 . 5: Removing the clitoris (clitorectomy). (Source: Alyce Santoro, for the author) |
|
figure з. 6: Reducing the clitoris (clitoral reduction). (Source: Alyce Santoro, for the author) |
the penis rather than at its tip (necessitating that the child urinate sitting down). Some of these operations address penile chordee, the binding of the penis to the body by tissue, which causes it to curve and have difficulty becoming erect—a condition that often results from intersexual development.69 Except for the most minor forms of hypospadias all involve extensive suturing and, on occasion, skin transplants. A male-assigned child may receive as many as three operations on the penis during the first couple of years of life, and even more by the time puberty hits. In the most severe cases, multiple operations can lead to densely scarred and immobile penises, a situation one physician has dubbed ‘‘hypospadias cripple.’’70
No consensus has formed about which technique consistently results in the lowest complication rates and necessitates the fewest operations. The enormous surgical literature on hypospadias is inconclusive. Every year dozens of new papers appear describing new surgical techniques, each supposed to give better results than the dozens of preceding techniques.71 Many of the surgical reports focus on special techniques for what the surgeons call ‘‘secondary operations’’—that is, surgery designed to repair previously failed surgeries.72 There are many reasons for the sprawling literature on hypospadias. The condition is highly variable and thus calls for widely varied treatments. But a re-
|
figure 3.7: Hiding the clitoris (clitoral recession). (Source: Alyce Santoro, for the author) |
view of the literature also suggests that surgeons take particular pleasure in pioneering new approaches to penile repair. Even medical professionals have remarked on this obsession with penis-building. As one prominent urologist who has a technique for hypospadias named after himself writes: ‘‘Each hypospadias surgeon has his fetishes.’’73