Intersex

Abstract

Sometimes individuals are born with genital, genetic, or hormonal characteristics that some people find confusing. From this phenomenon of “intersex,” a range of claims and counterclaims have flowed regarding sexual difference, medicine, gender, and identity.

Intersex was coined in 1915 by the zoologist Richard Goldschmidt to describe moths with atypical sex characteristics (Stern 1967: 156). The definition was soon extended to encompass several types of human “hermaphroditism,” but the latter word remained in circulation as a medical diagnosis throughout the twentieth century. Intersex is often popularly conflated with ambiguous genitalia — external sexual anatomy that cannot be easily described as entirely female or male, such as a larger-than-typical clitoris. However, for clinicians, an intersex diagnosis can refer also to attributes that are not apparent on the body's surface, including XXY sex chromosomes or indifference to the hormones that produce effects connotative of masculinity. What such intersex diagnoses have in common is the medicalization of a failure to classify the body as one of two sexes. That such a failure would be problematic is not obvious, nor is its medicalization; nonetheless, medical treatment of intersex is standard practice in the West. Treatment typically begins in childhood, even in infancy. It can extend over a lifetime in the case of hormonal interventions or repeated genital surgeries, despite assurances from generations of clinicians that the latest medical techniques will eradicate intersex before an individual is aware of it.

Within the last decade, medical guidelines have shifted to recommend psychological support and disclosure by default (Hughes et al. 2006: 154), but the extent to which these guidelines have been put into practice remains disappointingly unclear. After all, seminal clinical protocols from the 1950s made similar recommendations, yet led to decades of secrecy toward patients. The older protocols fostered a tenacious belief among many doctors and parents that genital surgery is a kind of preemptive psychological treatment, on the grounds that an individual's sense of gender will follow from the experience of having a dichotomously sexed anatomy. Several assumptions were implicit in this belief — that having an unambiguous and univalent gender is desirable; that it is better not to reflect consciously on the formation of one's gender; and, in turn, that early medical treatment can promote healthy gender development by averting conscious reflection on the formation of one's gender and its relationship (if any) to one's sexual anatomy. Taking these assumptions to their extreme, some clinicians have even argued that parents who fail to arrange early genital surgery for their sexually ambiguous offspring are guilty of child neglect (Rossiter and Diehl 1998: 61).

The architect of the traditional treatment protocols, psychologist John Money, was also an influential advocate of elective genital surgery for transsexual individuals. Consequently, an unresolved contradiction existed between Money's insistence that gender always develops in response to one's sex anatomy during childhood and his recognition that for transsexual individuals, gender develops divergently from the expectations set by one's anatomy (Diamond 1999: 1022). This contradiction facilitated the emergence during the late 1950s and early 1960s of a medical consensus over intersex treatment, for it gave Money's gender theory the fashionable appearance of being “interactional” in its refusal to polarize nature and nurture. Really, it was a theory composed of irreconcilable propositions (Downing, Morland, and Sullivan, forthcoming).

Nevertheless, the significance of Money's theory and its implications for clinical practice cannot be overstated, because the term gender itself was coined by him. It was a response to learning about an individual whose genital appearance was “feminine” due to intersex development and who was a doctor, husband, and father by adoption (Money 1973: 397). The ostensible discrepancy between this individual's masculine position in language and his sexual anatomy inspired Money to find a word for the former that reflected its difference from the latter. Money chose gender because the word connoted the arbitrariness of sexed pronouns in linguistics. Strangely, though, in the very article in which Money first used gender in its new sense, he also unveiled his signature recommendation that the treatment of intersex should eliminate any such discrepancy between an individual's gender and genitalia (1955: 254, 257).

Of course, one need not choose between an account of gender as determined by genital appearance and gender as an effect of language. I would say, following Michel Foucault's analysis of sexuality (1978: 155), that gender names one of many ways in which power — including medical power — grips bodies to produce individuals who are at once constrained and enabled by norms. To claim to belong (or not) to a gender is to orient oneself normatively in relation to others, seeking recognition for behaviors, attributes, and sensations that one regards as important, rather than to make a descriptive claim about one's genitalia. However, Money neither liked nor understood Foucault's work (Money 1998: 106–7), and to this day, medical sexology remains largely disengaged from relevant debates in the humanities over gender and the constitution of the self.

For instance, one large clinical team has asserted that medicine's task during the neonatal period is “to select a gender able to match the individual identity (II) of the child (which is invisible during this period), the social identity (SI) (which is the way ‘society’ looks at the individual and the only tangible identity approachable after birth) and the behavioural identity (BI), which is not formed yet” (Vidal et al. 2010: 312). This vague enterprise — where something invisible is aligned with something unformed in order to match something social (and where the enclosure of “society” in quotation marks suggests a lack of precision around that term too) — is not an acceptable rationale for medical treatment, especially where such treatment is irreversible. It is unscientific also, insofar as its success cannot be measured, merely inferred from the retrospective presumption that treatment has foreclosed “unbearable situations for the parents and the child” (ibid.).

I recognize that some parents of intersex infants are anxious to prevent, for example, people peering over their shoulders at their child's genitalia during diaper changing (Gough et al. 2008: 500). Yet it is surely never appropriate to scrutinize the genitalia of another person's child. The way to stop such behavior is to shame those who do it rather than to perform surgery. Treatment shames the child by suggesting that the problem is not the uninvited act of looking but the anatomy that is seen. Here is another key reason why the medicalization of intersex is a fundamentally erroneous project: it mistakes social norms and their transgression for properties of bodies, which can be modified or disambiguated through clinical interventions. But ambiguity is an interpretation, not a trait; and one cannot do surgery on a norm.

Further, the efforts by clinicians and families to eliminate intersex have traditionally entailed the strenuous production of silences — about hospital visits, scars, parental fears, injections, and even years of childhood — that actively create intersex as a state of strangeness rather than securing its removal from discourse. The experience of treatment as simultaneously objectionable and ineffective has been a central complaint of the intersex rights movement since its inception in the early 1990s (Chase 1998: 197–203). Consequently, activists have reappropriated intersex as an identity. To identify as intersex is to assert both that treatment does not work, insofar as medical interventions amplify the strangeness of one's intersex attributes, and that treatment should not be done at all, insofar as it discriminates against individuals on the basis of immutable characteristics. Such activism reveals that power never wholly grips or disciplines the body but produces opportunities for resistance to medicalization.

A collaborative effort in 2005 by patient advocates and clinicians to replace the medical terms intersex and hermaphrodite with disorders of sex development has highlighted the inseparability of power and resistance. To some commentators, the new nomenclature has usefully refocused doctors' attention on those phenomena that, unlike gender, can benefit demonstratively from medical intervention — such as a reduction in the risk of gonadal tumors or the facilitation of fertility. To others, the phrase disorders of sex development has nullified the advances made in the name of intersex activism and cast as disordered or disabled those individuals for whom intersex remains an identity (Reis 2007: 538). These contrasting outcomes are not mutually exclusive. Moreover, intersex continues to circulate among patient activists and humanities scholars. To exaggerate the capacity of medicine to determine the meaning of sexual atypicality would amplify medical power even while seeking to resist it.

In the context of trans studies, both intersex and transsexuality raise the question of what kind of body one needs to have in order to claim membership in a gender and whether a person's sense of belonging to a gender is colored by the experience of living in a body that has been touched by medical technology. Sometimes intersex and transsexuality have been construed as complementary examples of gender's construction — where the former shows gender's assemblage by force, and the latter its alteration by free will. But that analysis assumes the success of most intersex treatment and fails to account for the continuity of identity experienced by many trans individuals before and after medical treatment. Encounters with medicine neither cause trans people to change gender nor cause intersex individuals to acquire gender in the first place. Future scholarship might situate medical claims to treat intersex within the emerging canon of failure studies and help to divert academic and activist critiques of intersex medicine from that same disillusioning destination.

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