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From The New England Journal of Medicine, May 11, 2000
What is the relation among anatomy, sexual identity, and sexual practices? The authors of Intersex in the Age of Ethics argue that an ethical clinical response to intersexuality (i.e., the intermingling, in varying degrees, of male and female sex characteristics) will be possible only when this question can be answered on the basis of well-documented, long-term case studies of the lives of intersexual persons. To date, this information has not been collected and clinical practice is based on ill-founded assumptions.

This book reflects the search for an interim solution. It combines reviews of changing medical responses to intersexual persons with first-person accounts by intersexual people and their families. The 21 chapters develop a convincing case for the position that the relations among anatomy, sexual identity, and sexual practices are not rigidly fixed, but can vary in highly personal, unpredictable ways. The authors argue that, until better information becomes available, the least damaging course of action is to delay medical intervention until a person is in a position to make an informed decision about the options.

Social and medical attitudes toward people who do not conform to conventional categories of sex are influenced by our understanding of how anatomy influences social behavior. Until recently, the assumption in Western societies has been that anatomy determines sexual identity and, therefore, sexual preferences. In this view, there is a direct relation between a particular kind of body and both a particular sexual identity and a particular set of sexual practices. Sexual identity and practice follow from the body in a predictable and consistent manner. Given this assumption, it is hardly surprising that so much medical attention has been given to categorizing, defining, and reshaping intersexual bodies. The understanding is that once these unruly bodies have been made to conform, appropriate identities and practices will follow seamlessly.

In Victorian times, this shaping of the intersexual body was achieved by a kind of "conceptual surgery." The gonads were designated as the defining anatomical characteristic, and all other considerations were deemed irrelevant. If ovaries were present, the person was defined as female and would be expected to have only male sexual partners; if testes were present, the person was defined as male and would be expected to have only female sexual partners. By defining a sex for each ambiguous body, appropriate behavior was established for each person with such a body. The way in which such people experienced their bodies, identities, or sexual desires was not considered. Bodies mattered only to the extent that they were vehicles for ensuring that a person behaved in socially appropriate ways. As the range of clinical techniques expanded through the 20th century, the conceptual reduction of intersexual bodies was replaced by surgical reduction. The bodies of intersexual infants were carved to fit the social categories these children would be required to inhabit as adults. The birth of an intersexual baby became a "medical emergency," and the infant's ambiguous body was surgically "cured" to save the adult from social pathology.

As the first two parts of this book establish beyond doubt, the underlying assumption, that anatomy determines sexual identity and therefore practice, is not borne out in the life experiences of intersexual persons. Although we do not yet understand exactly how a person acquires a sexual identity or comes to desire specific types of sexual contact, it is clear that behavior cannot be predicted on the basis of an infant's gonadal, genital, or genetic makeup. As a result, surgical treatment of intersexual infants does not facilitate the unproblematic acquisition of a stable sexual identity, even though it is undertaken almost solely for this purpose. On the contrary, early surgery sometimes creates new problems: loss of sexual feeling, loss of fertility, lifelong urinary pain and dysfunction, and the social difficulties that follow from these conditions. The authors point out that being intersexual is a lifelong experience, irrespective of whether a person undergoes "corrective" surgery. Medical interventions, whether surgical or hormonal, do not "cure" a person of an intersexual condition. Rather, such interventions create further uncertainty with respect to the already ambiguous intersexual body, often compounding rather than reducing distress and confusion.

Although this book is full of diverse voices and styles of writing, it is a tightly focused collection with a consistent point of view. Each of the 21 chapters contributes to the development of the overall argument, and each chapter also has its own story to tell. These stories are variously academic and personal, powerful and unassuming, moving and disturbing, sad and joyful. However, all contributions are informative and compelling. No reader will put down this book unchanged.

Yvonne Marshall, Ph.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review
Here is the volume that clinicians, teachers, counselors, parents, feminists, and philosophers have needed to understand intersexuality. Cheryl Chase, Founder, Intersex Society of North America (ISNA) --Letter from Ms Chase

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