FIXING SEX
Intersex, Medical Authority, and Lived ExperienceBy KATRINA KARKAZISDUKE UNIVERSITY PRESS
Copyright © 2008 DUKE UNIVERSITY PRESS
All right reserved.
ISBN: 978-0-8223-4318-9
Contents
Acknowledgments..........................................................................................................xiIntroduction.............................................................................................................11. Taxonomies of Intersexuality to the 1950s.............................................................................312. Complicating Sex, Routinizing Intervention: The Development of the Traditional Treatment Paradigm.....................473. From Socialization to Hardwire: Challenges to the Traditional Treatment Paradigm......................................634. Boy or Girl? Bodies of Mixed Evidence and Gender Assignment...........................................................895. Fixing Sex: Surgery and the Production of Normative Sexuality.........................................................1336. Wanting and Deciding What Is Best: Parents' Experiences...............................................................1797. Growing Up under the Medical Gaze: Adults' Experiences................................................................2168. The Intersex Body in the World: Activism and Social and Medical Change................................................236Notes....................................................................................................................291References...............................................................................................................321Index....................................................................................................................343
Chapter One
Taxonomies of Intersexuality to the 1950s Until the middle of the twentieth century, medical intervention in hermaphroditism (later known as intersexuality) remained relatively uncommon, in part because the technological capacity to intervene, especially at birth, was limited. Unable to change the hermaphroditic body, medical investigations focused instead on attempting to understand and classify it. These investigations both informed and were informed by legal and social understandings of sex, the biological features generally used to define femaleness or maleness, in the West.
Over the past several centuries, a binary model of sex as unequivocally male or female has remained an almost universal axiom, despite evidence from human and animal biology calling this distinction into question. Over time, the biological markers of male and female have shifted, yet not the notion of sex as binary and discrete. This belief in two distinct sexes is an example of a concept so patently obvious and "natural" to most people that pointing to its historicity, and thus to its inherent unnaturalness, proves confounding, even incomprehensible to many. Yet the history of understandings of and approaches to hermaphroditism repeatedly points to attempts to use the phenomenon to reinforce the binary model, rather than to question it, from what have been called the Hippocratic and Aristotelian attitudes of the early modern period to the long-standing gonadal diagnostic principles of the nineteenth-century German pathologist Theodor Klebs (Daston and Park 1995; Dreger 1998a).
During the first half of the twentieth century, medical approaches to intersexuality moved further away from observation and classification and more toward intervention. Advancements in surgical techniques, the discovery of "sex" hormones, new understandings of sex differentiation in embryology, and the ability to test for sex chromosomes-as well as the consolidation of medical and scientific authority-not only shaped how somatic sexual difference was understood but also how intersexuality could be treated by suggesting sites and modes of intervention. Such intervention was-and largely remains-aimed at enabling the individual to fit, more or less superficially, into the binary model of sex.
The labeling of certain bodies as intersex is intimately and inextricably tied to understandings of supposedly normal male and female bodily characteristics. To call a body hermaphroditic, one must already have some idea of what normal male and female bodies look like, what traits they possess, and of the parameters of acceptable behavior for men and women. In this vein, medical practitioners have used knowledge, instruments, and technologies to read bodies, ascribe them a sex, and, when one is not evident, apply a sex in practice. In the case of intersexuality, sex is not merely conceived but enacted, thereby producing and reproducing the category sex and our understanding of what males and females are. Here I trace some of the earlier historical understandings of human reproduction, sexual difference, and hermaphroditism. While not meant to be exhaustive, this history serves as a background to later debates and shows that understandings of hermaphroditism, like much else, are subject to the constraints of time and place.
It might be tempting to dismiss earlier classificatory schemes for hermaphroditism (and for men and women) as quaint and inconsequential. Indeed, it is important to caution against drawing linear connections among conceptualizations of hermaphroditism in different historical epochs (Daston and Park 1995). Yet earlier strains of thought are echoed in current conceptualizations of intersexuality, including in tensions over what intersexuality is and how it should be treated.
A central point of concern and debate has been whether those classified as hermaphrodites are both male and female, neither, or some unique combination thereof. The range and intensity with which hermaphroditism has been an object of interest and speculation has fluctuated; however, over the past century, the cause, classification, and social status of hermaphroditism have proven of enduring medical and social interest. Heightened anxiety over hermaphroditism and the urgency of addressing it are linked to societal changes in gender roles and the corresponding associations between hermaphroditism and other moral and social concerns. Accompanying the intense fascination with and anxiety concerning hermaphroditism has been a need to classify gender-atypical bodies and normalize them-often relying on clinical medicine-to mitigate the threat they pose to the binary model of gender: in other words, the need to give them a single sex. Another issue is the enduring debate over what features should mark an individual's "true" sex, and who should make that determination. Since the late nineteenth century, medical discourses have exercised hegemony over political, legal, and even literary discourses, but this was not always the case. Finally, over several centuries of contemplating and addressing intersexuality in the West, theories for understanding and dealing with intersexuality have shifted considerably.
The Early Modern Period
Hermaphroditism has provoked curiosity for centuries because of its implications for the binary model of sex. Historians have demonstrated that understandings of sex differences before the modern period differed markedly from contemporary ones. Thomas Laqueur has argued that during premodern times, a one-sex model prevailed, in which understandings of sex focused more on similarity than on difference, and that "sex was a sociological, not an ontological category" (1990: 8).
Other historians have sought to complicate the binary periodization of sex into modern and premodern by turning an eye to the heterogeneity of conceptualizations within early modern accounts of hermaphroditism (Daston and Park 1995). Instead of a one-sex model, Lorraine Daston and Katherine Park propose two competing views of hermaphroditism, which they characterize as Hippocratic and Aristotelian because of their roots in the respective authors' early works on human generation, arguing that these were widely debated in early modern times. The Hippocratic view held that hermaphrodites were an intermediate sex exactly between male and female. By contrast, Aristotelians viewed male and female as opposite poles, with no possible intermediate points. For them, hermaphroditism was a condition primarily of the genitals, and thus hermaphrodites did not have an indeterminate sex, but rather doubled or redundant genitalia. In the Aristotelian view, an individual's true sex was always either male or female and thus never truly ambiguous. Not only was the genesis of hermaphroditism subject to debate within medicine but, Daston and Park assert, medical understandings and discussions of hermaphroditism did not dominate legal and political discussions. It was only in sixteenth-century France that hermaphroditism became strongly associated with sexual ambiguity (1995).
Intersexuality has attracted much recent attention because it calls into question a series of intractable dichotomies-nature versus culture, and male versus female, to name two-but according to Daston and Park these dichotomies were not relevant in the early modern period. After 1550, however, a frenzy of interest in hermaphroditism and a newly urgent association with morally charged sexual behavior and sexuality-such as sodomy, transvestitism, and even pornography-explicitly sexualized those labeled hermaphrodites. This intense concern and sexual association led to a resurgence of Hippocratic explanations of generation and sex difference. Hermaphroditism became "emblematic of all kinds of sexual ambiguity and associated with all practices that appeared to blur or erase the lines between the sexes" (Daston and Park 1995: 424).
From the sixteenth to the eighteenth century legal understandings of hermaphroditism in France and England were not always in accord with medical understandings of the time (Epstein 1990). Legal definitions of biological sex (and thus of hermaphroditism) were rigid, assuming two sexes, male and female. In contrast, medical understandings of biological sex as revealed in medical texts were more varied, complex, and contradictory, recognizing a spectrum of sex rather than the mutually exclusive categories of male and female. Legal sex identity was important because of its implications for marriage, property ownership, and civic status. Once a person was assigned a sex, even if prevailing notion held that it was the dominant rather than the "true" sex, the person was treated as a member of that sex for all legal purposes.
A significant question, of course, was who determined a person's sex. In the sixteenth-century, jurists relied on outside testimony from medical experts to determine a person's sex, rather than allowing adults in such cases to make determinations about their own sex. In contrast to Michel Foucault (1980) and Laqueur, who both argue that so-called hermaphrodites could freely choose their sex in the early modern period, Daston and Park contend that the decision was not without conflicts, in part because hermaphroditism, newly associated with sexual ambiguity, sexual deceit, and fraud, was seen as challenging the model of binary sex (1995: 426).
In the eighteenth century views shifted, leading to an emphasis on biological difference, not similarity, between men and women (Schiebinger 1989). Medicine extended sex differences to every part of the body from bones to brains, and these differences were codified by language: male and female sex organs, which had previously shared the same names, were now distinguished by separate terms. According to Laqueur (1990), this shift marks the emergence of the two-sex model of the human body.
The new emphasis on sex differences was not prompted by scientific developments. Indeed, scientific work provided numerous examples of discoveries that could have strengthened the one-sex model: for example, the budding field of embryology claimed that reproductive organs begin from the same embryonic structure. But the political, economic, and cultural transformations of the eighteenth century created the context in which identifying radical differences between the sexes became culturally imperative. Incommensurable sex difference was created despite, not because of, new scientific discoveries (Laqueur 1990: 169).
The Nineteenth Century
Despite their differences of opinion on understandings of sex difference in the early modern period, historians agree that scientific and medical interest in hermaphroditism increased markedly in the nineteenth century. In Hermaphrodites and the Medical Invention of Sex, the historian of science Alice Dreger describes how if a person designated a hermaphrodite visited a doctor, it was usually to receive a diagnosis, to relieve discomfort or pain, or for sex determination or revision; in some instances, the patient sought to marry or avoid conscription into the army. By the middle of the nineteenth century, there were two predominant classification systems for hermaphroditism, proposed by the French anatomist Isidore Georoy Saint-Hilaire and the British obstetrician James Young Simpson, with each system dominant in its author's respective country. By the mid-nineteenth century, the widespread expansion of hospitals enabled clinicians to see a greater number of individuals with rare conditions such as hermaphroditism, but except for a handful of the most notable clinicians, most saw very few.
In 1833, Saint-Hilaire presented his system for sex determination on the basis of the body's sexual organs and on whether or not they were concordant within an individual. He divided the sexual organs into six segments that he deemed the essential markers of sex. In this system of classification, one was truly male or female if all six segments were wholly male or female; any combination of male and female segments indicated hermaphroditism. Echoing earlier views, Saint-Hilaire argued that hermaphroditism was rooted both in excesses and arrests of otherwise normal sex development. Consequently he categorized individuals according to those segments in which they had excess and those in which they were lacking. Operating from an understanding of normal sex development, Saint-Hilaire believed, would enable an understanding of abnormal sex development. In turn, the study of abnormal variations could allow greater insight into normal sex development. As with many of today's investigations, his attempts to define the abnormal derived from the explicit desire to identify normal sex difference.
The long-standing British classificatory system emerged in the late 1830s when Simpson divided hermaphroditism into "spurious" and "true," categories that persisted through much of the century. Spurious hermaphrodites possessed genitals that were "approximate in appearance" to those of the opposite sex, whereas true hermaphrodites had a mixture of male and female organs. Characteristics of spurious hermaphroditism in the female could include a prolapsed uterus and an enlarged clitoris. In the male, spurious hermaphroditism included adhesion of the penis to the scrotum, hypospadias (an abnormal positioning of the meatus, the opening from which urine passes), and an extroversion of the urinary bladder (an abnormality in which the bladder protrudes outside the abdomen), because the latter were thought characteristic of the female sex. Examples of true hermaphroditism included the combination of an ovary and a testis, conflicting external and internal sexual organs, and a combination of male and female internal sexual organs.
Nevertheless, scientists and doctors did not agree on which traits conclusively determined sex, in part because few traits were sex exclusive. For example, ejaculate was an unreliable indicator because some men did not emit it, while some women did. Similarly, some women menstruated, but others did not. Cases of "doubtful" or even "mistaken" sex, where clinicians believed an individual was living as the "wrong" sex, elicited negotiation and disagreement among scientists and clinicians about which traits or body parts were masculine or feminine and thus about whether an individual should be considered male or female. Consequently, medical professionals relied on culturally derived and gendered notions about anatomy for sex determination. Clinicians, however, also made determinations about an individual's true sex with an eye toward the person's gendered behavior and sexual desire.
In the second half of the nineteenth century, doctors sought to build a broader consensus on true markers of sex. In 1876, the German pathologist Klebs was the first to suggest a taxonomy based exclusively on the analysis of gonadal tissue and on whether an individual had ovaries or testes. Klebs distinguished between pseudo- and true hermaphroditism, a classification system that remained until a 2006 call for a change in nomenclature. Those who had both ovarian and testicular tissue were called true hermaphrodites. Those who had a "doubling of the external genitalia with a single kind of sexual gland," that is, either ovarian or testicular tissue, were labeled pseudohermaphrodites (following Simpson's definition for spurious hermaphroditism) (Dreger 1998a: 145). Pseudohermaphrodites were individuals who were "really" male or female, as indicated by their gonads, but whose mixed external anatomy, especially their genitals, obscured their sex. The category of pseudohermaphroditism was further divided into masculine (testes present with female genitalia) and feminine (ovaries present with male genitalia).
Under Klebs's system, someone with a typically female body type and feminine external genitalia who also had testes would be classified as a male. Klebs codified an already widely accepted notion, namely, that gonads alone indicated an individual's true sex. If clinicians could find conclusive evidence of either ovaries or testes, the problem of sex determination was ostensibly solved.
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