Thursday, August 31, 2006

[English] Are you ambiguous, my dear?

- article published in Dagens Nyheter, 20010914

By Sara Edenheim
(Translated from the Swedish by Curtis E. Hinkle)

Most people feel that biology and sex are linked together in a very obvious way - we are all born female or male. There are differing opinions as to whether to consider our gender roles as an inescapable consequence of this or that they are a culturally enforced construct. There are very many who point out that biology has very little, if anything, to do with gender roles. A very significant example is the treatment of those called intersex which is a very tangible example of how medicine and science are more or less compelled to correct "nature."

We all have a sex at birth. We are sure of that. We don't all have the same sex at birth. We are sure of that too. However, it is not well known that everyone's sex cannot be categorized as either male or female. Intersex is a relatively common phenomenon which means that the person is born with genitalia that are hard to define: micropenis/large clitoris, with/without a vagina with XY chromosomes and so forth in a series of different combinations. Intersex, in other words, is someone whose anatomy has both basic female and male elements. But what does that really mean? If we look more closely at sexual anatomy in general, we begin to see that there is not any single, "natural" distinction between the sexes that we could choose and from this viewpoint, we are all intersex really. (Many will object here that it is easy to categorize men and women: women are those who can bear children. But to choose this characteristic and to use it to define "female" is not in accordance with reality, since there are both infertile women and fertile intersex "men".)

What is meant then when we say a child has "ambiguous genitalia"? How small must a penis be to become ambiguous, how big can a clitoris be before it is seen as abnormal? The only starting point we have for coming up with a definition of intersexuality is by determining how often doctors feel it is difficult to determine the sex of a newborn. American research indicates that according to records available that doctors consider that approximately 1 newborn in 1,500 is intersex based on the appearance of their external genitalia. If we also include children that doctors consider to have "cosmetically unacceptable" genitalia, for example non-intersexed girls with a large clitoris, the statistics increase drastically. Intersexed children in Sweden are usually operated on in Astrid Lindgrens Children's Hospital in Stockholm.

Intersexuality - like transsexualism - is classified as an illness which needs to be treated by surgical intervention. There are cases of intersex in which the child's health is in jeopardy, but this is very seldom the result of how the genitalia look, but rather because of internal complications. Despite this, intersexuality is generally treated as a serious problem which 'for the best interest of the child' should be solved as soon as possible. The solution consists of different types of cosmetic surgeries, (re)construction of the genitalia, as well as informing the parents which specific sex the child 'belongs to' and eventually hormone treatments may be added. For certain, most doctors insist that in such instances the child will be socialized in his gender identity, a perspective that they share with constructivist feminist researchers. But the former are proceeding from the basis that a gender identity is absolutely necessary for a child to have a stable upbringing and a sense of integrity and wholeness, as well as the assumption that there are typical feminine and masculine characteristics and behaviors which are linked to male or female genitalia respectively. Whereas feminists are attempting to point out the disadvantages with gender roles as they exist in our society and that they do not have anything to do with bodily functions, whereas the position taken by doctors is that gender roles are essential, fixed and desirable.

According to medical professionals there are no specific regulations to determine which sex an intersex infant will belong to. All they base their decisions on are 1) the operation should take place as soon after birth as possible 2) they construct the sex which is the "easiest" in light of the physical factors present in each case 3) they will ensure that the individual, if possible, will be able to engage in sexual intercourse once adult.

In practice, this means first of all that the patient has no possibility in determining for themselves the shape and appearance of their genitalia and secondly that more intersex infants are surgically assigned female than male. This first of all involves a violation of the individuals freedom of choice. And secondly it exposes sexist and heterosexist assumptions about sex and gender. The official explanation is that it is technically simpler to construct a functional vagina than a functional penis. In one article a doctor candidly states that "a functional vagina can be constructed in virtually everyone."

In other words, there are more demands that need to be met before constructing a penis even though it is relatively simple to demonstrate that a vagina is just as complicated and therefore no simpler to construct: it is lubricated with fluids when sexually stimulated, it changes size, is sensitive, etc. The "hole" which doctors call a vagina is nothing more than a hole and cannot give sexual pleasure.

"Sexual adjustment and adaptation" in other words mean different things depending on which sex you happen to end up belonging to. The actual implementation of these routine practices end up simply being that a child with a sufficiently long penis, without a vagina and ovaries, as well as XY chromosomes, will be surgically made a boy. All other combinations are deemed by doctors to be girls. It is clear that there is something extremely special about being a man, since it requires both a certain penis size along with corresponding chromosomes that match, whereas the female category is less complicated and more flexible from this point of view. All who do not fulfill the criteria for manhood (big penis, XY chromosomes) are assigned to the "second sex". It is extremely revealing that doctors are of the opinion that it is urgent that the child which has passed the "manhood test" be operated as early as possible so as to prevent "traumatic memories of having been castrated". Children who undergo the construction of a clitoris and/or vagina, on the other hand, often wait to a period of time between seven months and up till four years old and sometimes even later. It seems apparent that no one seems to be concerned that these children will suffer from traumatic memories from having been genitally mutilated. The doctors and the experts however know since Freud's time that women have a sense of being castrated regardless.

The question which comes to mind is obvious: why do the children need to be operated on? The answer can be found in the writings of the queer theorist Judith Butler who points out that in everyday life we reproduce categories by means of language and other behavior, that is, it is performance (performative acts) which maintains difference between people. This means that it is impossible to separate sex (biology) and gender (social role). Sex is constructed in the same manner as gender. The midwife's pronouncement: "It's a boy!" is in other words the first act in the construction of the sex [of the child] since this statement contains information for those surrounding the child how they are to categorize the child's body and simultaneously how they are to interact with the child in the future.

The problem is that there are no performative behaviors which have been elaborated for us to use when we are placed before a person whose sex we cannot determine. Instead, we try desperately to add up all the "female" against all the "male" characteristics we can find in the person, so as to be able to categorize them with the characteristics which add up to the most points. This is more or less the method which the Swedish Health Service recommends for doctors to use and most likely the one we would use if presented with an individual whose sex was hard to determine. All of this is quite simply grounded in our need to answer one disturbing question: "What is this person, really?" The question is disturbing because we realize within a concrete and material context that the categories we have been taught to see as natural are either impossible to maintain or that we must revise our view concerning the binary opposition of man/woman.

The regulations associated with intersexuality have been created in order to deal with what is viewed to be a problem. Sexologists and surgeons are convinced that they are acting in the best interest of the child. To suggest that an operation is not really necessary would most likely be viewed as inhumane and with cynicism. We consider that society can not permit a child to grow up neither a girl or a boy. "It" would not have any clear gender identity! Which in reality means nothing more than that "it" would not know which toys should be played with, which careers were suitable or which box to tick off on official documents. And most of all: "it" would not have a name or even a personal pronoun, since our language is a fundamental factor in the process of creating what is masculine and what is feminine.

There is nothing that indicates that an intersexed person (who remained intersexed) would have any problem with their gender identity if those surrounding them did not treat them as different, as an object or a monster. To draw a comparison here with the debate about the right of homosexuals to adopt or to have artificial insemination is justified. Intersexed children - as well as children of homosexuals - are not reported to have any serious problems if "we" do not treat them with prejudice and stress that they are different. From a constructivist perspective there is simply no rational necessity to tick off a box which certifies which sex we are on forms and there is no logical reason to know which sex category a child belongs to unless we want to make sure that the child knows what they can and cannot do because of their sex category. The lack of rational views about this and its usefulness can have no other explanation than the politically imbued naturalisation of sex and gender differences.

The treatment of the intersex is a paradox in a legal system which expressly prohibits genital mutilation. In cases in which a girl's clitoris is operated on because it is considered too big, the paradox is obvious - we reject non-Western arguments for female circumcision as misogynist, but the question is how is the argument for mutilating a girl with a clitoris which is "too big" different from the other which is rejected as superstitious by doctors? But even in the case of intersex, we are actually dealing with nothing more than genital mutilation, for there is no other argument for operating and determining the sex of an intersexed person (or any other individual at all) than to make them fit a social norm - or a superstition if you wish.


Butler, Judith: Bodies That Matter - on the discursive limits of sex,
Routledge, New York (1993)

Dreger, Alice Domurat: 'Ambigouous Sex' - or Ambivalent Medicine?, The
Hastings Center Report, vol. 28:3, s.24-35 (1998) (även

Edenheim, Sara: Lag och Genus - att konstruera biologiskt kön, uppsats
Juridiska institutionen vid Lunds universitet (2001)

Hird, Myra: Gender's Nature - intersexuality, transsexualism and the
'sex'/'gender' binary, Feminist Theory, vol.1(3):347-364 (2000)

Socialstyrelsen redovisar: Fastställelse av könstillhörighet 1978:2
SOU 1968:28 Intersexuellas könstillhörighet


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