surgery

Malena Maxwell is a biology and physics double major.  She is interested in pursuing a career in the field of medical devices and took this course to educate herself on the evolution of medicine and medical practices throughout history.

 

“It’s a boy!” A proclamation such as this is usually the first phrase to come out of a physician’s mouth when they deliver a baby into the world. According to theorist Judith Butler, this is not only a statement, but also a “performative utterance” that assigns a sex and gender to that baby [1]. Yet in about one in every two thousand births an infant’s sex is unable to be determined at first glance [2].

Throughout history, the medical profession has been observing and intervening in the lives of those who do not strictly fall into the category of male or female. By analyzing how medical authorities have othered, altered, and fixed the bodies of “hermaphrodites” and the intersexed, we can see that they have constructed a rigid, two-sex system that reinforces heterosexual and male hegemonic social norms.

Prior to the 1850’s, medical professionals defined a hermaphrodite as someone who had both male and female sex organs. According to historian Elizabeth Reis, this situation was rare, so the definition of the hermaphrodite expanded to include all cases in which there was doubt about one’s sex in the mid-nineteenth century [3]. This broader definition was refined to the categories of true hermaphrodites, male pseudohermaphrodites, and female pseudohermaphrodites, after Theodor Albrecht Klebs proposed that the gonads were the primary indicators of sex in 1876 [4]. Only about five percent of those with ambiguous sex were classified as true hermaphrodites, while the others were viewed as pseudohermaphrodites [5]. This uneven statistic resulted in the rejection of the hermaphrodite as an additional category of sex. In the early 1900’s, the term “intersex” began replacing “hermaphrodite” in the medical field. It signifies that one is in between sexes instead of being both at the same time. However, this term is still not recognized as a category of sex today [6].

The hermaphrodite and the intersexual were and currently are denied as categories of sex because they threaten the two-sex, heteronormative structure of American society. Most public structures and institutions are built around the two-sex system of male and female and the heterosexual nuclear family. Bathrooms and locker rooms are labeled “men” and “women,” and until recently, the institution of marriage was reserved only for those of the opposite sex. Previously, an American’s legal sex influenced their participation in marriage, property ownership, and politics [7]. If someone was neither legally a male nor female, there were not explicit answers to the questions of whether or not they could vote or own property, and whom they could marry. By challenging these gender-based rights, intersexuals threatened the long-standing structure of America’s two-sex society.

Intersexuals also threatened the heteronormative structure of society. They did so by “accidently” partaking in homosexuality [8]. For example, perhaps someone with ambiguous genitalia lived their life as a woman and married a man. If she later sought medical attention and during her examination a physician claimed she had male genital organs, the physician could declare that she was, in fact, male. In this case, the newly declared male would have now been sexually intimate with another male, leading to accidental homosexuality. Homosexuality has been viewed negatively in our society because it challenges the structure of the nuclear family and previously assigned gender norms. Hermaphrodites represented deviations from the two-sex, heterosexual structure of society. Their discrepant sex led society to view them as a cultural and social issue that needed to be solved [9].

Physicians, surgeons, and other medical authorities developed a solution to this “problem.” Since most individuals with ambiguous genitals were not considered true hermaphrodites, physicians believed that they were “really” a man or woman [10]. Physicians took it upon themselves to uncover or discover someone’s true sex that they claimed was there all along. Before the Golden Age of Medicine and the emergence of surgery, physicians did this by observing, diagnosing, and classifying those who with ambiguous genitalia. Most of these patients were adults when their sexual anomalies were discovered, which left little room for medical intervention.  This all changed when hospitals became the primary site of birth in the early 20^th century.  As physicians became more involved in the birthing process, they also became more involved in the medical management of intersex infants [11].

Medical authorities were more able to diagnose, treat, and “fix” intersexuals as they practiced mastery over sexual determination in infants. From 1876 to 1915, what was known as the Age of Gonads, gonadal tissue largely determined the true sex of intersex individuals [12]. After this time frame, physicians placed more emphasis on secondary characteristics such as external genitals, chromosomes, internal organs, and hormone production [13]. Out of these attributes, external genital appearance became the primary indicator physicians used to uncover an infant’s “true sex” [14].

When analyzing an infant with unclear genital structure, physicians usually looked for similarities between normal anatomy and the abnormal anatomy of the child [15]. An enlarged clitoris or a micropenis usually dominates what is characterized as the “abnormal” anatomy that needs to be surgically corrected. Each case of enlarged clitoris or micropenises are handled differently depending on the chromosomal sex of an infant and their ability to produce hormones [16].  Although these characteristics are factors in sexual assignment, most emphasis is placed on the sized of the enlarged clitoris or micropenis. If a boy’s phallus is not large enough, he is considered a girl, not a boy. This method of medical management of intersex infants portrays various implications of what it means to be a male or a female.

Medically, a male had to have XY chromosomes and an appropriately sized penis (large enough for female penetration). Only ten percent of intersex infants met this medical standard, while the other ninety percent were, as you could say, not good enough to be considered males [17]. The majority of intersex infants fell into the category of female and their bodies were constructed to have a “functional” vagina (capable of penal penetration) [18]. These medical standards for males and females were rooted in male, heterosexual hegemony. Only those with large enough penises could be considered men because otherwise they would not be able to have sex with a woman. This implied that women were simply vessels of sex for men’s use and pleasure. While physicians surgically constructed bodies that reflected male and heterosexual hegemony, John Money reinforced these ideals along with standard gender norms through his gender development theory.

John Money was the first man to propose that gender was not solely linked to someone’s anatomy. Beginning in 1995, Money and his colleagues theorized that “gender and children are malleable” and that through psychology and medicine, a child’s gender could be molded to match their surgically constructed genitalia [19]. According to this theory, newborns to children of eighteen months of age did not have an established gender identity, unlike adults [20]. This logic was why physicians primarily began targeting infants for genital construction surgeries in the mid-1950s and 1960s [21]. If surgery was conducted early on in a child’s life and parents practiced the proper rearing techniques, their child would establish a gender identity that was aligned with their genitals. Responsibility for the child’s future fell into the hands of both physicians and surgeons to uncover the true sex and surgically alter the genitals to match, along with the parents to rear their child so they would establish the corresponding gender identity.

Money describes the proper rearing techniques in his book, Man & Woman, Boy & Girl. When raising a boy, parents encouraged them to be dirty, loud, energetic, and initiative. Parents also told their boys that they were going to be fathers and husbands in the future, so education and work were necessary in order to financially support a family.  The rearing techniques of a girl largely deviated from those of a boy. When raising a girl, parents were instructed to grow their hair out and put them in dresses. Girls were to be neat, polite, quiet, and passive. The most important aspect of raising a girl was emphasizing that she would be a mother and wife someday, so domestic skills, such as cooking and cleaning, were essential [22]. These key aspects to raising boys and girls largely reflect and reinforce gender norms in which boys are the masculine breadwinners while girls are passive and polite housekeepers.

The medical management of intersex infants and John Money’s gender development theory has constructed sex, gender, and sexuality. American society often uses these terms interchangeably, however they each have different meanings with respect to human existence. Sex is the anatomical and physiological make up of a person. Gender refers to an individual’s self-identification and outward presentation, usually reflected through displays of femininity and masculinity. Sexuality relates to an individual’s sexual desire or acts. It is important to differentiate these three terms in order to understand the influence American medicine has had on them.

Medical intervention in the lives of intersexuals has constructed sex into a rigid two-sex system. By denying intersexuals a category of sex and instead labeling them as between male and female, medical authorities have decided that there are two natural and normal sexes, male and female. The medical management of intersex infants has also influenced gender. Money’s rearing techniques reinforced the notion that males are masculine men, females are feminine women, and gender should match an individual’s designated sex. Money’s theory, along with the surgical creation of males and female, constructed sexuality as well. Women were medically constructed for penal penetration and reared to become wives, whereas men were constructed to penetrate females and raised to be successful husbands.

When we restrict integral qualities of human existence to binary systems, we define who is human and who is not. When intersexuals are labeled in our society, we fail to give them more than just a name. Their exclusion will not go away until society, as a whole, is able to reframe its perspective on what it means to be human. Today, humans are defined as either male or female with respective genders and sexualities. Recognizing intersexuality as a true identity will require the reconstruction of social thought. Men are more than just a sizable penis and women are more than just a penetrable hole. Freeing identity from these two hard-ingrained markers would both open up space for the intersexed and liberalize men and women from their confined spheres.

 

Endnotes

[1] Sara Salih, “On Judith Butler and Performativity,” in Sexualities and Communication in Everyday Life: A Reader, ed. Karen E. Lovaas & Mercilee M. Jenkins (Thousand Oaks: Sage Publications, 2007), 61-62.

[2] Cheryl Chase, “Hermaphrodites With Attitude: Mapping the Emergence of Intersex Political Activism,” GLQ: A Journal of Lesbian and Gay Studies 4 no. 2 (1998): 189.

[3] Elizabeth Reis, Bodies in Doubt: An American History of Intersex (Baltimore: Johns Hopkins University Press, 2009), 43.

[4] Anne Fausto-Sterling, Sexing the Body: Gender Politics and the Construction of Sexuality (New York: Basic Books, 2000), 38.

[5] Suzanne J Kessler, “The Medical Construction of Gender: Case Management of Intersexed Infants,” Signs 16 no. 1 (1990): 5.

[6] Alice Domurat Dreger, Hermaphrodites and the Medical Invention of Sex (Cambridge: Harvard University Press, 1998), 31.

[7] Katrina Alicia Karkazis, Fixing Sex: Intersex, Medical Authority, and Lived Experience (Durham: Duke University Press, 2008), 34; Fausto-Sterling, Sexing the Body: Gender Politics and the Construction of Sexuality, 39.

[8] Dreger, Hermaphrodites and the Medical Invention of Sex, 76.

[9] Suzanne J Kessler, Lessons from the Intersexed (New Brunswick: Rutgers University Press, 1998), 32.

[10] Reis, Bodies in Doubt: An American History of Intersex, 29.

[11] Karkazis, Fixing Sex: Intersex, Medical Authority, and Lived Experience, 38-39.

[12] Geertje Mak, “‘So we must go behind even what the microscope can reveal’: The Hermaphrodite’s ‘Self’ in Medical Discourse at the Start of the Twentieth Century,” GLQ: A Journal of Lesbian and Gay Studies 11 no. 1 (2005): 68-69.

[13] Kessler, “The Medical Construction of Gender: Case Management of Intersexed Infants,” 11.

[14] Morgan Holmes, Intersex: A Perilous Difference (Selinsgrove: Susquehanna University Press, 2008), 50.

[15] Reis, Bodies in Doubt: An American History of Intersex, 43-44.

[16] Kessler, “The Medical Construction of Gender: Case Management of Intersexed Infants,” 11.

[17] Chase, “Hermaphrodites With Attitude: Mapping the Emergence of Intersex Political Activism,” 192.

[18] Dreger, Hermaphrodites and the Medical Invention of Sex, 184.

[19] Kessler, “The Medical Construction of Gender: Case Management of Intersexed Infants,” 6-8.

[20] Karkazis, Fixing Sex: Intersex, Medical Authority, and Lived Experience, 55.

[21] Reis, Bodies in Doubt: An American History of Intersex, 141.

[22] John Money, Man & Woman, Boy & Girl: The Differentiation and Dimorphism of Gender Identity from Conception to Maturity (Baltimore: Johns Hopkins University Press, 1973), 118-125.

 

 

Further Readings

Colapinto, John. As Nature Made Him: The Boy Who Was Raised As a Girl. First edition. New York: HarperCollins, 2000.

Eugenides, Jeffrey. Middlesex. New York: Picador, 2002.

Preves, Sharon E. Intersex and Identity: The Contested Self. New Brunswick: Rutgers University Press, 2003.