Intersexuality and the Battle of the Scalpel

Tales of intersexed people, the 'hermaphrodites,' pop up throughout history and cultures. The Greek mythological god Hermaphroditus, child of Hermes and Aphrodite, became both male and female after the nymph he loved begged the gods to join them within one body (Porter 1998). According to Plato, there were three sexes, males, females, and intersexed. Laws dictating the legitimacy of inheritance, marriage, and voting rights for hermaphrodites appear in the Talmud, 16th century Scotland, and 19th century Connecticut (Fausto-Sterling). Hermaphrodites, both natural and self-altered, became Berdaches, an integral part of some Native American cultures, many South Asian intersexed hijra were considered special and exotic sexual partners, high priced delicacies on the prostitution market (Porter 1998).

While it is very difficult to know the frequency of intersexuality, it is estimated that intersexual infants may constitute as many as 4% of births. In many ways, the terms hermaphrodites and intersex serve as catch-alls for numerous aetiologies and three major subgroups of individuals with a mixture of male and female characteristics (Fausto-Sterling, 1993). These categories are broad and encompass many combinations and structures of both internal and external sexual characteristics, but are grouped as following: The 'true' hermaphrodites possess one testes and one ovary, male pseudohermaphrodites haves testes and some aspect of the female genitalia, but no ovaries, and female psuedohermaphrodites have ovaries and some aspect of male genitalia but no testes. The physical characteristics as well as the emotional inner lives of the people in each subgroup are extremely complex and vary enormously within each category (Jarrah et al, 2000).

In humans, as with all mammals, instructions within the sex chromosomes X and Y determine the sex of the fertilized egg. Humans all begin as females, and without the introduction of the Y chromosome gene called SRY the default is for the gonads to develop into female sex organs (ovaries, vagina, clitoris, etc.) When SRY is introduced early in gestation there is a cascade of events that usually leads to male phenotypic sexual characteristics and organs (penis, testes, etc). Thus, usually females have two X chromosomes, and males have an X chromosome and a Y chromosome (Who's Who in Sex-Determination Research). Yet, there are many ways that uncommon combinations of sexual chromosomes or the expressions of those chromosomes can lead down sexual development along atypical paths. For example, if a fertilized egg has both X and Y chromosomes it usually develops into a male, but if the Y-linked SRY gene is, for one of many reasons, inactive during its short critical period the fetus will usually develop the external signs of a female but may also develop internal testes or both testes and ovaries. Many times this condition is not detected until a physician examines the individual to examine why the individual does not experience menstruation or is infertile. This is just one of thousands of ways that an individual can develop ambiguous genitalia or intersexuality (Faletra). The paths that a fetus takes to become intersexed not only affect the physical body of the individual. In his book, Genome, Matt Ridley describes how the interplay between the sex chromosomes and which parent they are inherited from affects the way that gender plays naturally into the development of the human brain and behavior. He explains that "male behavior is systematically different from female behavior in most species and the difference has an innate component. The brain is an organ with innate gender." Thus, the developmental differences that result in intersexuality play important roles in the both the body and mind of the individual (Ridley).

Modern western culture is fixated on the idea of two sexes, to the point that children born with ambiguous sexual characteristics are often put quickly under the knife and carved into one of the binary categories. The documentary Is it a Boy or a Girl? says that there are 500 gender surgeries performed every day on newborns in the United States (2001). Ideas of gender run deeply, and in most cultures whether we or designated male or female determines our rights, drafts, votes, and family structure. So, what does it mean to a culture that tends to view gender as black and white that there are some people who, by nature, exist outside these categories?

Although the incidence rate of hermaphorditism is low, there are numerous causes of these disorders and they manifest themselves in the body in many ways. When a child is born with ambiguous genitalia or a form of hermaphroditism, many physicians advocate determining a sex for the infant as soon as possible, and taking the 'proper' surgical steps. A study published in the European Journal of Pediatrics in 2002 explores the processes that doctors take or should take to determine a sex for an infant born with intersex characteristics. This study claims that "A correct aetiological diagnosis is of paramount importance because, together with the aspect of the external genitalia, it has important bearings on the choice of the sex rearing." This study says that the process of diagnosing the cause of intersexuality involves many difficulties that need to be resolved using a close collaboration between clinicians, biochemists, and molecular biologists. Doctors search for chromosomal conditions in which the infant is born with malfunctioning sex chromosomes, are missing a chromosome, or have an extra chromosome. They also search for chemical or endocrine conditions, testing to see that hormone balances are 'normal' and chemical inhibitors and enables that play on different genes are working correctly. Finally, they examine the physical condition of the intersexed characteristics, to determine how their sexual organs function and are laid out in the body. Even once a possible cause is determined, there may not be a consensus regarding the proper sex assignment. In 52% of the cases that they studied no diagnosis of sex could be reached through an extensive clinical and laboratory work-up or sequencing for chromosomal or chemical conditions. It is often difficult to reach an aetiological diagnosis because of the variability of individual cases, and because it is often impossible to understand how an individual's body is working without invasive exploratory surgery (Morel et al, 2002).

Yet, despite the difficulties that physicians have in determining the 'proper' gender for an intersexed infant, most infants have a gender picked for them and their genitals operated on almost immediately. Most modern physicians are able to use physiological and surgical technology to catch most intersexuals at the moment of birth, and can immediately channel such infants into hormone and surgical treatment. The idea is that, by assigning the infant a sex, the child's altered genitalia and sex rearing will allow them to slip into society as 'normal' people. In the past there were incidents where a doctor immediately performed genital surgery on a child without parental permission, and often people are unaware of their intersex condition.

A study published in the online journal Pediatrics in 2002 focused on post-surgical 'woman' adults who have a 46,XY karyotype and presented a degree of undermasculinization of their genitalia as infants. They used semi structured interviews to assess how much the participants knew about their condition, if they were satisfied with their knowledge, and if they desired additional education about their intersex condition. Overall, the study found that half of the patients were not well informed about their medical and surgical history. The individuals whose external genitalia more closely resembled male genitalia were told that they were intersexed 72-80 percent of the time. But individuals who were born with genitalia that looked more like female genitalia were only told of their condition 36% of the time. Over half of the patients reported being dissatisfied with their knowledge of their surgery or with the amount of explanation they were given concerning what it meant to be intersexed (Berkovitz et al, 9/2002). This shows a discrepancy between what physicians know about their patients condition and what the patients themselves understand. This discrepancy is often exacerbated by having gender-rendering surgeries performed on individuals too young to understand what is happening to their bodies.

Many intersex societies, such as the Intersex Society of North America (ISNA), have argued that many patients are unhappy that parents and physicians made the decision for them to have a gender surgery. The ISNA advocates postponing surgery until children are able to decide for themselves which gender they want to be, or whether surgery is necessary at all. The 2002 European Journal of Pediatrics study acknowledges that, in severe cases where the gender of rearing is debatable, doctors should delay the decision and not perform surgery directly after birth. The study says that this delay is traumatic for parents but, "it is now becoming clear that the decision about the timing and nature of genital surgery should be based upon what is thought to be best for the patient, not for the parent." This is a revolutionary idea hat is only now coming to the forefront of medical discourse about the intersexed. This study says that it is arguably permissible that, in difficult cases, delaying for several weeks may allow for more biological and molecular tests to be completed, and they can assess how the patient responds to non-surgical androgen treatment, which may enhance sexual characteristics non-surgically (Morel et al, 2002). The ISNA suggestions go even further, advocating waiting years before performing a gender-altering surgery. ISNA's suggestions, while illuminating, do not answer all of the issues involved in deciding how to medically treat intersexed infants. The ISNA does not address how their suggested wait time would affect hormone treatments, which has the potential to be gender altering but can lose its power to influence the body if there is too much delay.

Some studies claim that most intersexed people are happy with the decisions that their parents and physicians have taken with their gender rearing. Another article published in Pediatrics in 2002 claimed that most of the intersexed men and women in their study were satisfied with their gender rearing and surgeries. They found that intersexed who were surgically altered to be men averaged three times as many genital surgeries as those who were altered to be women. Also the appearance of the post-surgical male was rated significantly worse for that of post-surgical women. Yet, despite these poor appearance ratings by physicians, most of the individuals in this study were satisfied with their body image regardless of their post-surgical sex designation. They were also mostly satisfied with their sexual experiences, and with their sense of masculinity or femininity. Yet, the study found that 23% of participants, both post-surgically male and female, were dissatisfied with their parents' and/or physicians' choice of sex rearing.

Therefore, while the majority of the people in the study were satisfied, one out of every five participants expressed a wish that their gender had not been thrust upon them under a surgical knife. Considering the weight of the issue of having an incorrect gender imposed upon an individual, one out of five is not an exceptionally good record. While this study concludes that both male and female sex rearing of the intersexed offer equal amounts of satisfaction for the patients, it is just as important to note that male and female sex rearing also offer equal amounts of dissatisfaction between these individuals, whether male designation or female designation (Berkovitz et al, 8/2002).

Despite the criticism of gender surgery, a study written by the Endocrine Society attempted to put to rest the doubts of critics of the surgical treatment for the intersexed. This study said that such controversy exists due to a lack of long-term information regarding the medical, surgical, and psychosexual outcomes in intersexed adults who underwent genital surgery. The conductors of this study decided to conduct a long-term assessment, via questionnaires and medical examination, to gauge the physical and psychosexual status of 14 women, ages 25-65, with documented complete androgen insensitivity syndrome. Individuals with complete androgen insensitivity syndrome, are considered women, as they have external female sexual characteristics, but mostly the male organs inside their bodies. The women in this study had had their male internal sexual organs surgically removed, were given estrogen treatment, and were designated female by their physicians and parents. They found that, in general, most of the women were satisfied with their sexual function, their psychosexual development, and their gender rearing. They were satisfied having been raised as females, and none of the women desired switching genders. What the study is not quick to point out, and one can only find by closely examining their data and charts, is that all of the women in this study, with one exception, underwent their gonadal surgery between the ages of 13 and 21. While it is not discussed, one would assume that by the age of 13 these women were given an amount of choice in whether or not to have surgery and as to what gender they would prefer relative to the amount afforded to most intersexed, who are put under the knife soon after birth. This relative ability of the participants to chose their gender probably has a strong influence on their positive feelings about their gender surgeries and rearing (Berkovitz et al, 7/2002).

At the root of the debate over surgical measures is the question as to whether intersexuality is an abnormality that should be fixed, or if it is another extension of gender that our culture does not acknowledge. The main argument for surgery is that physical alteration may allow an intersexual to have a 'normal' life. Advocates of immediate surgery often point to school locker room showers as an example of why surgery must be done as soon as possible to 'correct' a child's genitals. They point out the amount of teasing that a child with ambiguous sexual characteristics would undergo in such a situation, and many situations before and after. As the studies have shown, individuals are often pleased with the sex that their surgeon carved out for them, and are satisfied in their gender roles.

Despite the apparent benefit of avoiding extra childhood bullying, critics point to that not-too-small minority that say that are unhappy with the gender that was chosen for them, and to the deep psychological implications of that dissatisfaction. They also point to the many intersexed who do not entirely understand their condition nor what was done to them by physicians. Finally, they point at a society that is fixated upon placing people into one of two gender categories and harboring an inability to see past them. It says much about our culture that it is difficult to intermingle ideas of physical femaleness with maleness, and that we would rather lop off the micropenis and testes of intersexed to make him/her fit into the categories in our minds than wait until we're sure that it's what the individual would chose. It is uncertain what is the ethically or more physiologically beneficial path to take with the intersexed, but it tells a lot about our staunchly binary ideas of gender that we even have to ask. Anne Fausto-Sterling, the author of The Five Sexes, says that the idea of people with both or neither sex frightens people, and makes us reevaluate what it means to have gender. "Inasmuch as hermaphrodites literally embody both sexes, they challenge traditional beliefs about sexual difference: they posses the irritating ability to live sometimes as one sex and sometimes as the other, and they raise the specter of homosexuality (Fausto-Sterling, 1993)." While the ultimate question of how to treat intersexed people is one that currently has no absolute answer, it is clear that our society cannot answer this question without further awareness and exploration of the causes of intersexuality, the effects that different intersexed conditions have on the bodies and minds of afflicted individuals, and the sociobiological consequences on individuals who undergo gender surgery and rearing.



Works Cited:

Berkovitz, Gary D.; Brown, Terry R.; Gearhart, John P.; Meyer-Bahluburg, Heino F.L.; Midgeon, Claude J.; Money, John; Wisniewski, Amy B. The Endocrine Society. July 2000. Complete Androgen Insensitivty Syndrom: Long-Term Medical, Surgical, and Psychosexual Outcome. The Journal of Clinical Endocrinology and Metabolism, Vol. 85, No.8 p2664

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