Date: Wed, 16 Nov 1994 13:35:49 -0500 (EST) From: ESTESWL@RASCAL.GUILFORD.EDU (WHAT HAD TIME TO SAY TO THIS? WHAT COULD SPACE PROVE?) Subject: intersexuality Date: Tue, 15 Nov 1994 16:28:00 -0800 Reply-To: Queer Studies List Sender: Queer Studies List From: Cheryl Chase Subject: intersexuality definitions, bibliography To: Multiple recipients of list QSTUDY-L Several people have mentioned to me that there were requests for information about intersexuality on this list recently. I hope the enclosed information helps. ISNA is a peer support and activist organization for all those at risk of stigmatization or surgical mutilation because of intersexual anatomy. Cheryl Chase Intersex Society of North America PO Box 31791 San Francisco CA 94131 What is Intersexuality? Our culture conceives sex anatomy as a dichotomy: humans come in two sexes, conceived of as so different as to be nearly different species. However, developmental embryology, as well as the existence of intersexuals, proves this to be a cultural construction. Anatomic sex differentiation occurs on a male/female continuum, and there are several dimensions. Genetic sex, or the organization of the "sex chromosomes", is commonly thought to be isomorphic to some idea of "true sex". However, at least 1/400 of the population have a karyotype other than XX or XY. Since genetic testing was instituted for women in the Olympic Games, a number of women have been disqualified as "not women," after winning. However, none of the disqualified women is a man; all have atypical karyotypes, and one gave birth to a healthy child after having been disqualified. The sex chromosomes determine the differentiation of the gonads into ovaries, testes, ovo-testes, or nonfunctioning streaks. The hormones produced by the fetal gonads determine the differentiation of the external genitalia into male, female, or intermediate (intersexual) morphology. Genitals develop from a common precursor, and therefore intermediate morphology is common, but the popular idea of "two sets" of genitals (male and female) is not possible. Intersexual genitals may look nearly female, with a large clitoris, or with some degree of posterior labial fusion. They may look nearly male, with a small penis, or with hypospadias. They may be truly "right in the middle", with a phallus that can be considered either a large clitoris or a small penis, with a structure that might be a split, empty scrotum, or outer labia, and with a small vagina that opens into the urethra rather than into the perineum. In some cultures, including Native American and modern India, intersexuality is associated with a special social role. In ancient Rome, intersexual infants were considered ill omens and were exposed at birth. In our culture, even acknowledgement of the existence of intersexuality is essentially taboo. When an intersexual infant is born, the parents are confronted with a shocking fact that violates their understanding of the world. Physicians treat the birth of such an infant as a medical emergency. A medical team, generally including a surgeon and an endocrinologist, is roused from bed, if need be, and assembled to manage the situation. Intersexual bodies are rarely sick ones; the emergency here is culturally constructed. The team analyzes the genetic makeup, anatomy, and endocrine status of the infant, "assigns" it male or female, and informs that parents of their child's "true" sex. They then proceed to enforce this sex with surgical and hormonal intervention. The parents are so traumatized and shamed that they will not reveal their ordeal to anyone, including the child as he/she comes of age. The child is left genitally and emotionally mutilated, isolated, and without access to information about what has happened to them. The burden of pain and shame is so great that virtually all intersexuals stay deep in the closet throughout their adult lives. Intersexuality: An Annotated Bibliography Intersexuals speak for ourselves Alvarado, Donna. "Intersex," West Magazine section of Sunday San Jose Mercury News, Jul 10, 1994. Describes the life stories of Cheryl Chase and Morgan Holmes, based on personal interviews. Photos of Holmes. Opinions of intersex specialists Grumbach of UCSF and Gearhart of Hopkins (surgery is necessary to prevent parents from treating child as an outcast) are contrasted with personal experience of Chase and Holmes (surgery experienced as mutilation, causing sexual dysfunction). Anne Fausto-Sterling criticizes intersex specialists as unwilling to follow up patients to determine the outcome of their interventions. "Once a dark secret," BMJ 1994; 308:542 (19 February). A woman with XY karyotype and "testicular feminization" (androgen insensitivity syndrome) briefly relates how damaging she has found the secrecy surrounding her condition. "Mine was a dark secret kept from all outside the medical profession (family included) but this is not an option because it both increases the feelings of freakishness and reinforces the sense of isolation. It also neglects the need for the counselling of siblings. "Gender identity in testicular feminization," BMJ 1994; 308:1041 (16 April). This letter responds to "Once a dark secret" in the 19 Feb issue. The author discusses the issue of gender identity, criticizes the secrecy and the labelling of an individual with androgen insensitivity as "male" or "hermaphrodite. "Be open and honest with sufferers," BMJ 1994 308:1042 (16 April). The author of this letter has also been subjected to secrecy surrounding her androgen insensitivity. This secrecy produced a "lifetime of unnecessary secrecy, shame, delayed action, and great damage to my personal and sexual identity and self esteem." Two British support groups are referenced: Androgen Insensitivity Syndrome Support Network, c/o Mrs Jackie Burrows, 2 Shirburn Avenue, Mansfield, Nottinghamshire NG18 2BY, tel 0623 661749, and Vaginoplasty Support Network, c/o Sheila Naish, Royd Well Counselling, 35 Royd Terrace, Hebden Bridge, West Yorkshire HX7 7BT, tel 0422 845304. Holmes, Morgan. "Re-membering a queer body," Undercurrents, May 1994: 11-13. Published by Faculty of Environmental Studies, York University, 4700 Keele St, North York, Ontario Canada M3J 1P3. Ms Holmes, who was subjected during childhood to "clitoral recession" surgery which removed most of her clitoris, analyzes the cultural imperative to surgically alter intersexual children's genitals. "The medical definition of what female bodies do not have and must not have: a penis. Any body which does possess a penis must either be designated 'male' or surgically altered. ... In the minds of doctors, bodies are for procreation and heterosexual penetrative sex. ... I would have liked to have grown up in the body I was born with, to perhaps run rampant with a little physical gender terrorism instead of being restricted to this realm of paper and theory. Someone else made the decision of what and who I would always be before I even knew who and what I was." Holmes, Morgan. "Medical Politics and Cultural Imperatives: Intersexuality Beyond Pathology and Erasure," Master's Thesis, Interdisciplinary Studies, York University, September 1994. Deconstructing the medical viewpoint Fausto-Sterling, Anne. "The Five Sexes: Why Male and Female are Not Enough," The Sciences, March/April 1993:20-24. Reprinted on New York Times Op-ed page, March 12, 1993. See also the Letters from Readers in the July/August 1993 issue. Fausto-Sterling questions the medical dogma that, without medical intervention, hermaphrodites are doomed to a life of misery. What would be the psychological consequences of raising children as unabashed intersexuals? Imagine a society in which sexuality is celebrated for its subtleties and not feared or ridiculed. The author's acceptance of the Victorian classification of intersexuals as male, female, and true pseudo-hermaphrodites is unfortunate, as is her naivite about the success of surgical intervention. Kessler, Suzanne. "The Medical Construction of Gender: Case Management of Intersexed Infants." Signs: Journal of Women in Culture and Society, 16(1) (1990):3-26. Ms Kessler interviewed six medical specialists in pediatric intersexuality to produce an account of the medical decision making process. She describes the processes by which cultural assumptions about sexuality in effect supersede objective criteria for gender assignment. Kessler concludes that the key factor in making a decision is whether or not the infant has a "viable" penis. Lee, Ellen Hyun-Ju. "Producing Sex: An Interdisciplinary Perspective on Sex Assignment Decisions for Intersexuals," Senior Thesis, Human Biology: Race and Gender, Brown University, April 1994. Ms Lee ananalyzes medical literature for clinical recommendations concerning the diagnosis and treatment of intersexed infants, while invoking deconstructive feminist theory to critique the medical "management" of ambiguous genitalia. Her interdisciplinary approach places intersexuality within a broader discourse of sex and gender, disputing the binary male/female opposition as a social construction. Especially valuable is her transcription of an interview with "Dr Y", an intersex specialist who acceded to be interviewed about gender assignment under the condition that his identity be disguised. Analyzing gender Fausto-Sterling, Anne. Myths of Gender, New York: BasicBooks, 1985. Many scientists respond to the issue of sexual equality and the social and political upheaval that has accompanied it by offering us their insights, suggesting in all sincerity that, however well-intentioned, the women's liberation movement and its fellow travlers want biologically unnatural changes that would bring grief to the human race. The question of nature vs nurture - biological vs social determinism - remains a hotly debated topic. In analysing male/female differences, scientists peer through the prism of everyday culture. Their hidden agendas bear strong resemblances to broader social agendas. Kessler, Suzanne, and McKenna, Wendy. Gender: An Ethnomethodological Approach, Chicago, The University of Chicago Press, 1978. The authors use the ethnomethodological perspective to analyze gender as a social construction. For a psychologist to ask the question, "How are girls different from boys?" overlooks the fact that in order to ask the question, she must already know what girls and boys are; she must be able to attribute gender to actual individuals. How does this process of gender attribution work? What can we learn about gender by considering the lack of cross-culturally valid criteria for distinguishing sex? The relationship between biology and gender as a social construction demonstrates that the latter provides the foundation for the former. How do children learn the rules for constructing a world of two genders? Lewontin, R., Rose, Steven, Kamin, Leon. Not in Our Genes, New York: Pantheon Books, 1984. The authors, a prominent genetecist, neuroscientist, and psychologist, offer a scathing rebuttal of biological determinism and sociobiology, demolishing the claim that what an individual can do or become is fixed by their genetic makeup. The discussion of sex and biology, of intersexual karyotypes, and of Money and Erhardt's work on gender are of particular interest. Alternative concepts of gender in other cultures Herdt, Gilbert (ed). Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History. New York: Zone Book, 1994. Third Sex, Third Gender assembles recent historical and anthropological work to address the question: Is sexual dimorphism inevitable in human affairs? Byzantine eunuchs, the modern history of cultural perceptions about homosexuality, females in the Balkans who were "social males", Native American Berdache, Indian Hijra, American transgenderists all militate against an affirmative answer. Most relevant, however is Herdt's own presentation of 5-alpha reductase male pseudo-hermaphrodites among the Sambia in Papua New Guinea: they are assigned at birth to a third sex, although the Sambia worldview codes but two genders. Three cheers for his scathing deconstruction of Imperato-McGinley's analysis of 5-alpha reductase hermaphroditism in the Dominican Republic. Nanda, Sarena. "Hijras as Neither Man nor Woman," The Lesbian and Gay Studies Reader, ed Henry Abelove et al. New York: Routledge, 1993. The Hijra of India are born as men or as hermaphrodites. Most join after maturity, but when Hijra discover an intersexual infant, they claim it as their own. Indians, more than Westerners, find meaningfulness in "in-between" categories. Roscoe, Will. "Bibliography of Berdache and Alternative Gender Roles among North American Indians." Journal of Homosexuality 14(3-4) (1987):81-171. Roscoe, Will. The Zuni Man-Woman, Albuquerque: University of New Mexico Press, 1991. Williams, Walter L. The Spirit and the Flesh: Sexual Diversity in American Indian Culture. Boston: Beacon Press, 1986. Popular Reports of Intersexuality Majeski, Tom. "Surgery changes Russian child's sex," Knight-Ridder News Service. San Jose Mercury News, Jul 25, 1994. A Moscow family, distressed by the genital anatomy of their one year old son, brings him to US for a free sex change, clitorectomy, gonadectomy, and vaginal construction, courtesy of surgeons Reinberg (U Minn) and Gonzales (Wayne State U). Article characterizes child as having mixed gonadal dysgenesis, "both male and female chromosomes, ... genitals of both sexes". Esoterica Berlin, Meyer and Zevin, Shlomo Josef (eds), Encyclopedia Talmudica, 21 vols (Jerusalem, 1974), 1:386-99. Extensive Talmudic regulations regarding obligations of hermaphrodites. The medical viewpoint: etiologies, "treatment" Conte, Felix A. and Grumbach, Melvin M. "Pathogenesis, classification, diagnosis, and treatment of anomalies of sex," Chapter 109 of Endocrinology, ed. Leslie De Groot, Saunders 1989. In depth presentation of etiology, diagnosis, and progress of intersex and related conditions, by two pioneers in the research. Grumbach was a student of Lawson Wilkins (considered the "father of pediatric endocrinology") at Hopkins in the 1950's. No flexibility evidenced about sex assignment, early surgery, or issues of sexual function. Emans, S. Jean Herriot. Pediatric and Adolescent Gynecology, Boston: Little, Brown and Company, 1990. The chapter on intersex in this medical textbook provides a guide to diagnosis and lays out the standard medical dogma. To wit, value large penises with urethral meatus at the tip, and female fertility. Assign most intersexual infants female and remove clitoral tissue, construct vagina. Hendricks, Melissa. "Is it a Boy or a Girl?," Johns Hopkins Magazine, Vol XLV, No 5, Nov '93, pp 10-15. See also letter published in Feb '94 issue. Surgeons at Hopkins are "artists of genital surgery", who can "carve a large phallus down into a clitoris, create a vagina using a piece of colon, mold labia out of what was a penis." They concede, however, that the surgery is performed in order to alleviate discomfort of parents and relatives, and that they cannot say whether or not their patients will be able to have orgasms. Why do they assign most infants female? "You can make a hole, but you can't build a pole," quips one surgeon. Money, John ed. Biographies of Gender and Hermaphroditism in Paired Comparisons, New York: Elsevier, 1991. The most extensive case histories available. Unfortunately, surgical details are sketchy, and discussion of sexual function reveals Money's devaluing of female sexuality. Money, John, and Erhardt, Anke. Man & Woman Boy & Girl, Baltimore: The Johns Hopkins University Press, 1972. A thorough presentation of the state of knowledge of human sexual differentiation as of 1972. Includes a number of cases, with photos, of intersex. Money, John. Gay, Straight, and In-Between, New York: Oxford University Press, 1988. A presentation of Money's ideas on development of sexual orientation. Includes discussion of sexual differentiation, illuminated by discussion of intersex development. Money, John. Sex Errors of the Body , Baltimore: The Johns Hopkins Press, 1968. Money, John. Sex Errors of the Body and Related Syndromes , Baltimore: Paul H. Brookes Publishing Co., 1994. "A guide for counseling children, adolescents, and their families." Money's stand is that there are only two sexes, and intersexual infants must be surgically "corrected" to fit into one or the other. Money is horrified by the idea of a male growing up with a small penis, but unaffected by females whose genitals have been damaged by removal of the clitoris. Physicians are encouraged to mislead parents about the actual condition of their child. In the introductory chapter of this new edition of Sex Errors, Money takes a moment to heap scorn on social construction theory, singling out Fausto-Sterling in particular. van Seters A. P. and Slob A. K. "Mutually gratifying heterosexual relationship with micropenis of husband," Journal of Sex and Marital Therapy 4(2) 1988: 98-107. This report is invaluable for its presentation of several intersexed individuals who reached adulthood without surgical "correction". The individuals, all living as men with very small penises, presented at the authors' clinic for sex therapy. They are sexually functional, and a small amount of talking therapy helped them and their partners to come to terms with their differences. The authors note without objection, though, that today infants like these patients would be assigned female and have their penises removed. Slijper, F. M. E, et al. "Neonates with Abnormal Genital Development Assigned the Female Sex: Parent Counseling," Journal of Sex Education and Therapy, Vol 20, No 1, 1994, pp 9-17. Intersex specialists are encouraged to treat sex assignment and "corrective" genital surgery as an emergency. The specialists should determine the sex assignment and prevent the parents from understanding that their child is actually intersexed. They should teach the parents to lie about their child's condition. Surgery on the infant's genitals will alleviate the parents' emotional distress. The parents should be assured that their child will be heterosexual. Stecker, John, Horton, Charles, Devine, Charles, McCraw, John. "Hypospadias Cripples," Urologic Clinics of North America, Vol 8, No 3, Oct 1981. Hypospadias surgery is prone to many complications, and oftenrepeated many times. As many as 150 different surgical techniques are used. Hapless victims of repeated hypospadias surgeries are "hypospadias cripples ... trapped in a surgical maelstrom in which every operation may in fact, make matters worse." Woodhouse, C. R. J. "The sexual and reproductive consequences of congenital genitourinary anomalies," Journal of Urology, Vol 152, pp 645-651, Aug 1994. A surgeon discusses prospects for adult sexual function, notes that 75% of male assignments with "ambiguous genitalia or micropenis have normal intercourse". "My own experience is that men with the smallest and most deformed penis can have a satisfying sexual relationship with their partner." It is therefore "particularly important to establish whether the alternative treatment, gender reassignment, has better results." Note: The Intersex Society also has an extensive bibliography (not annotated) of reports of treatment of intersexuality in medical journals since 1950. This includes some 70 individuals who were able to keep their visibly intersexed genitals intact.