Surgical alterations/reconstruction of 5-ARD individuals’ genitalia is by no means necessary, but hormone replacement therapy is practiced to ensure a “normal” psychosocial male or female gender identity development. Evidence might suggest that DHT hormonal therapy before puberty might increase penile size for those adopting a male identity. There is no surgery necessary to insure proper sexual functioning of the phallus in most individuals, because it takes place naturally after virilization. A female identity is maintained through intensive hormonal therapy. For a female gender identity, one must undergo gonadectomy (removal of the gonads) prior to puberty, and will start ethinyl estradiol or conjugates estrogens therapy at an appropriate age. There is some debate between endocrinologists as to what age is appropriate. The majority of endocrinologists suggest that hormonal therapy before thirteen years of age will cause premature epiphyseal fusion; however, some specialists are beginning therapy around the age of ten when gonadroptropin levels begin to rise (LH and FSH). As a result, medical professionals aren’t sure of the long-term side affects that hormonal therapy will have on 5-ARD individuals, or for that matter any intersexed person. Bone mineralization inadequacy is another possible outcome of hormonal therapy. Although there have been no studies on 5-ARD patients, individuals with Androgen Insensitivity Syndrome have reported a decrease in bone mineralization by dual clinical osteoporosis and photon studies (Wilson; 2004, 9).
Surgical intervention is based on societies standards of normal, not because intersexuality is a life threatening condition. By operating on intersexed children we are denying them liberties, which “normally” reared XX and XY individuals with passing genitalia receive. Intersexed children are denied their right to give legal consent, assigned into (possible) the wrong gender, which they have to struggle with and after surgery are left with diminished-to-painful sexual response (Wilson; 2004, 9).
“It’s a boy! It’s a girl! Oh, wait, how can we fix this?”
Historically, physicians have become the final arbiters and gatekeepers of defining health and illness (Crawford). Within this realm medical professionals are giving the authority to perpetuate, an all too familiar, bipolar gender classification; which presents the theory that every human should be born either male or female. The fact is, biologic variation of sex coexists in nature with the typical XX and XY individuals; however, such variations are a threat to societies concepts of gender differences and the politics behind gender equality (Kimmel; 2000, 2). Intersexed or “ambiguous” genitalia do not constitute as a disease, but intersexed people do constitute a failure to depict a particular definition of normality (Dreger; 1998, 9). In this section I will analyze –the authoritarianism of physicians, the sexist nature of sex constructive surgery, and how medical professionals violate an intersexed individual’s right to informed consent.
In the late fifties, Dr. John Money, a pioneer in psycho-sexual development, designed the “optimal sex rearing” paradigm that he felt would be the most ethical treatment for intersexed children, and would allow for genital ambiguous individuals to develop a “normal,” heterosexual sexuality and gender identity (www.trans-cademics.org). Money theorized that ones gender was, in totality, governed by environmental factors as opposed to biological factors that were involved in the development of ones gender identity, and that intersexed children would adopted whatever gender they were (re) assigned. He argued that by “fixing” genital ambiguity it would allow intersex children to have a “normal” and psycho-socially healthy male or female gender identity, because development is based on the appearance of the genitals (Dreger; 1998, 25). Assuming that ones gender was a determinate of ones sexuality, Money was tragically mistaken.
Money’s fallacy of the nurture versus nature debate is best illustrated with the past emergence of the John/Joan case, which proved it is imperative that sex, gender, and sexuality must be deconstructed. One’s gender is a “social-psychological construction that parallels acceptance of one’s biological sex” (Kimmel; 2000, 74); however, if ones genitalia have been removed it becomes necessary to distinguish between sex and gender. In the case of John/Joan, Davis Reimer was raised as a girl along the side of this twin brother. David, at the age of twenty-two months, was assigned into a female sex and gender after an unconventional circumcision and bad medicine left him with mutilated genitalia. Because it’s easier to “make a hole than construct a pole” David became the “puppet” for Money’s nurture over natures determinate of sexual identity. As a result, David suffered years of –misidentity, psychological abuse, confusion, teasing, and counseling (Auleb; 2004, 197). Eventually, David was informed of his pseudo identity and immediately reverted to his biological sex (XY), but only after –testosterone injections, a double mastectomy, surgery to create a penis, depression, and uncountable hospitalization infections (). In can “concluded that the evidence seems overwhelming that normal humans are not psychosocially neutral at birth but are, in keeping with their mammalian heritage, predisposed and biased to interact with environmental, familial, and social forces in either a male or female mode” (Dreger;1998, 2).
The basic assumptions about human gender, sexual identity and sexual re-assignment, or what makes one male or female, are now being evaluated because of David Reimer. Although David was not intersexed, medical professionals took it upon themselves to surgically operate in the name of ethical and moral concern to normalize. Because of the advances in medicine, as well as, surgical technology physicians are able to expand their jurisdiction, and are now the supervisory body of sexual intermediacy. Since the 1950’s, medical professionals have obtained a comprehensive knowledge of surgical techniques, and sophisticated understanding of hormonal and biochemical functions of the body; because of this, physicians are able to eliminate the outward manifestation of hermaphroditism. Medical professionals are able to “catch” intersexuals at the time of birth and perform surgery to eliminate “abnormal” physical genital traits ().
Medical professionals possess a specialized body of knowledge that creates an unequal partnership, with the parents, in surgical decisions. Because physicians’ are the researchers and writers for the medical journals, the parents’ perspective on intersex management is invalidated by the professional dominance of the physician. Although parents might not have a strict criteria for normal genitalia, the physician does and encourages surgical intervention by classifying ambiguous genitalia as a disorder (Kessler; 1995, 9). So, the parents take the surgeon’s recommendation to operate, and believe normal genitalia are a factor in their child’s psycho-social development.
Biomedicines claims its treatment for intersexuality focuses solely on the prevention of psychological problems and the elimination of confusion about the child’s sexual identity. Medical professionals permanently decide the sex and gender identity of the intersexed individual only forty eight hours after birth (Dreger; 1998, 73), because these children fall between the cracks of the male/female divide. Physicians function under uncertainty, in a sense that they operate knowing (re)assignment is not necessary, and risk assigning the wrong gender (Freund; 2003, 229). Is this really in the best (present/future) interest of their patient? No! In fact, sex (re) assignment surgery is extremely sexist.
The psychosocial theory of treating genital ambiguity has led specialists to adopt a set of “practical” rules and regulations. According to Dreger, if you are a genetic male (XY) you must have an “adequate” penis size of at least 2.5 cm to be assigned a genetic male. If a genetic males phallus was less than 2.5cm medical professionals will label his genitals “inadequate,” and assign him into a female gender and perform reconstructive surgery (Kessler; 1995, 1). Yet, genetic females born with ambiguous genitalia are assigned a female gender no matter how masculine their genitals appear (Dreger; 1998, 7). This is done chiefly to preserve the female reproductive capacity, and to align their genital appearance and physiological ability with a reproductive role (Dreger; 1998, 23).
It is much more difficult to create a “functional” penis than a vagina. The standard theory among surgeons remains: that a “functional vagina can be constructed on anyone, because their definition of “functional” is a hole big enough to accommodate an average-sized penis; however, the ability to self-lubricate and orgasm is not encompassed in the definition of a “functional.” Let’s define a “functional” penis. The penis must –be larger than 2.5cm, be able to satisfy female during vaginal penetration, become erected and flaccid at the appropriate times, expel semen and urine, and appear “believable.” Such regulations imply that constructing a female is virtually fool proof, but assigning a male identity to an intersexed child requires experience and caution to ensure the penis will be a successful promoter throughout malehood. Because of the rigid concepts of anatomically “normal” genitalia, treatment protocols are obviously sexist in its “asymmetrical treatment of reproductive potential and definitions of anatomical ‘adequacy’” (Dreger; 1998, 8). Surgical reconstruction to correct ambiguous genitalia is inseparable from the heterosexist ideology, which discriminates against non heterosexual behaviors or orientations. The rules for appropriate gender variation reinforce penile-vaginal penetration (heterosexual intercourse) as normative behavior.
It is not clear whether sex (re)assignment surgery would constitute as legally and ethically informed consent. Parents’ of intersexed children, who aren’t educated or counseled in intersex management, are presented with a psychosocial theory that intersexed children should not be told the truth about their condition, because they risk for malformed gender identity. This allows medical professionals to control the flow of information to the patient (Freund; 2003, 227). In a college base study, Kessler asked a group of men and women to evaluate the quality of their genitals. Kessler proposed a hypothetical question, and asked the women to “suppose you have been born with a larger than normal clitoris and it would remain larger than normal as you grew into adulthood. Assuming that physicians recommended surgically reducing your clitoris, under what circumstances would have wanted your parents to give them permission?”(6).
About a fourth of women indicated they would not have wanted a clitoral reduction under any circumstances. About half would have wanted their clitoris reduced only if the larger than normal clitoris caused health problems. Size, for them, was not a factor. The remaining fourth […] could image wanting their clitoris reduced of it was larger than normal, but only if having surgery would not result in a reduction in pleasurable sensitivity (6).
The men were then asked to consider being born with a smaller than normal penis (micropenis) and that their physician recommended a phallic reduction and sex reassignment into a female gender (Kessler; 1995, 7). All but one male objected to surgery, and indicated that having a small phallus is not a justifiable factor for sex reassignment (hence, the John/ Joan case). Kessler’s male study revealed that a cultural expectation of adequate penis size does not constitute a male identity, but rather biology does.
It has not been determined whether medical or surgical treatment will be beneficial to intersexed psychosocial problems. However, intersexed persons are coming forward to protest biomedicine’s “compassion” to “normalize” their genitalia. If intersexuality is non-life threaten, then reconstructive genital surgery only perpetuates, the all too familiar, male/female dichotomy. The medical professionals, as authorities, are giving the power to define maleness and femaleness, and the criteria for normal genitalia. Natural variations in genitalia are now medicalized; because genital ambiguity defies what biomedicine considers normal. Clearly, society will only accept the bi-polar male and female genders. But, I propose this: if genital ambiguity only threatens the comfort level of the physician to designate the child’s gender role, then why not wait until intersexed children are able to express what identity suits them? It’s their genitalia after all.
Bibliography
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2. Dreger, A. Domurat. 1998. ‘Ambiguous sex’–or ambivalent medicine? Hastings Center Report, 28 (3), 1-10.
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