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An article by Morgan Holmes published in Undercurrents (May 1994: 11-13) by the Faculty of Environmental Studies, York University, 4700 Keele St., North York, Ontario, Canada, M3J 1P3.
What follows is the text of Morgans article followed by some correspondence between an AISSG UK member, Morgan and Cheryl Chase (Director of the Intersex Society of North America - ISNA).
For information about the author see AIS in Articles/Books.
In the spring 1993 issue of The Sciences, Brown University geneticist Anne Fausto-Sterling, citing the work of John Money, indicates that approximately four percent of the population is, to some degree, intersexual: they either possess physical characteristics of both officially recognized sexes or they have chromosomes which indicate a sex which are 'contradicted' by their physical appearance [footnote 1, see end of article]. In Toronto, the four percent figure translates into roughly 88,000 people. Yet little has been written about intersexuality, although its concerns often intersect with those of feminist and queer theory. This paper deals with feminist issues in patriarchal medicine and its relation(s) to intersexuality (and intersexuality's inherent ability to challenge arguments for the 'natural' basis of heterosexuality).
Sex is generally understood as the biological basis for assertions of gender: i.e. the body is the incontrovertible facticity which cannot be denied. The starting point of this paper, the one I could not proceed without, is that sex, while I agree that it is located in/on the body, is not absolute -- that is to say that sex is not clearly defined, not something which all bodies adhere to simply and easily. Sex is also constructed, not only at the ideological level of gender, but at the physical/biological level of bodies and surgery. The frequency with which intersexuality occurs, in which species it is more prevalent, its causes and manifestations and its variances are studied so that all traces of intersexuality in humans can he erased. Texts and research dealing with intersexuality make no provision for intersexuality to exist except as a pathological condition. Instead of using the knowledge to designate a space in which intersexuality constitutes a sex or set of sexes which is consistent with the forms that the human body may take -- just as male and female are presently seen as medically consistent configurations of human form -- the knowledge is used in order to make diagnoses which effect, not merely closure on the sexes as dimorphic and complementary, but also lead to the erasure of physical states that challenge this vision of human existence.
To understand the problem of intersexuality, it is necessary to understand how normal sexual development occurs and how this process may be disturbed. [my emphasis] (Edmonds 1989:6)
By common definition a female body is one capable of reproduction and not possessing a penis while a male body possesses a penis and is not capable of gestation. However, when it comes to 'managing' intersexed children, it is the size of the phallus [footnote 2] that counts:
Choice of gender identity thus depends on the external genitalia and the possibility of future coital adequacy. When the sex assignment is definitively made, the gonads that conflict with the assignment should be electively [according to whom?] removed. (Emans and Goldstein 1990:62)
This means that when a genetically male child (XY) is considered incapable of achieving 'normal' heterosexual activity as a male, he will be reassigned as female even though the micropenis would be functional (i.e. sexually sensitive and able to carry semen and urine).
In this paradigm female bodies are not understood through any positive attributes but are defined only through lack of a penis. Indeed, the possibility of fertility in a genetic female (XX) -- and not the adequacy of the phallus -- justifies the removal of the phallus/clitoris. [footnote 3]
It should be emphasized that '46,XX persons with CAH [footnote 4] are females and are potentially fertile. Thus, regardless of the appearance of the external genitalia, the sex assignment should be female. (Emans and Goldstein 1990:58)
The removal of the phallus/clitoris in both male and female intersex 'cases' results in bodies which, regardless of their genetic constitution or initial appearance, conform to the most important definition of the female: absence of the penis. This system of treatment sees fertility as the most important defining factor of an XX body and the least important defining factor of an XY body (for which the main issue is adequacy of sexual performance). Furthermore, this system takes heterosexuality as an a priori imperative. The contradiction in this logic is that XY intersexes revised to be 'female' will be infertile even though fertility is used to validate the removal of a phalloclit [footnote 5] from an XX intersexual. [footnote 6] This contradiction is why I am insisting that there is no positive definition of female bodies in medicine. Ultimately, fertility is irrelevant to femaleness while potency remains an essential feature of maleness.
Intersexual bodies, in the medical framework, are abnormal insofar as the 'true' sex is obscured by some malformation of the external genitalia and/or the gonads and reproductive organs. The medical presumption is that by relying on the scientific criteria which distinguishes male from female, the true, sex of intersexed bodies can be revealed. In addition, because of the issue of phallic adequacy and because "...the surgery necessary to convert to female is simpler..." [footnote 7] (Edmonds 1989:14) even in a chromosomally male body, a phallus which cannot meet the medical criteria to become a certifiable penis will be removed.
It is true that penises come in all sizes, as do hands and feet... In the case of the microphallus, however, the organ is definitely too small to permit satisfactory copulation. It is, therefore, fairly common to recommend to the parents that they raise such a baby as a girl. This is, of course, a very difficult decision for them to make, and they must be given all the information needed to understand the rationale of the decision. (Money 1968: 40)
The rationale is, of course, primarily functional and also assumes that a dominant, heterosexual mode of penetrative sex is the only appropriate one. There is no allowance made for intersexed persons to grow up in the bodies they possess so that they can eventually decide for themselves what normal' sexual function is. The recommended surgical procedure assumes that the normal male sexual role is to insert a penis of acceptable size into the appropriate receptacle (i.e. a vagina -- which can he constructed for those not born with one).
Heterosexist, functionalist medicine furthermore assumes that if one is born with a vagina, the appropriate sexual activity will he as receptor and not penetrator. Thus, when a body which has been designated female (either through chromosome testing or anatomical standards) possesses a phallus, the surgical procedure remains roughly the same as that for treating the micropenis: remove the phalloclit in a process of either partial or total clitorectomy.
When I underwent surgery in 1975 a procedure known as 'clitoral recession', in which the midsection is removed and the glans re-attached to the base, had come into practice and was used in my case. Although I consider the surgery to be a serious amputation in which a perfectly functioning body part is stolen, D. Keith Edmonds takes the procedure more lightly:
Preservation of the glans has become fashionable in an attempt to preserve clitoral sensation.... The clitoral skin is incised along its length on the dorsal surface, carefully opening the sheath of the corpora to preserve the neurovascular bundle and shelling out the remainder of the corpora.... The corpora having been excised, the glans is then sutured onto its base. [my emphasis] (Money 1968:62)
In addition to the similarity of the surgical procedure involved in the removal of a micropenis, the interests of heterosexual 'normalcy' are being similarly served. The assumption is that a body which possesses 'female' reproductive organs and a vagina must not be a body which is also capable of assuming the sexual privilege of penetration usually reserved for males. After all, if the phalloclit grows large enough, the lines between heterosexual and homosexual behaviour could he severely blurred and the heterosexual matrix would be severely threatened.
The patriarchal desire to protect the rightful place of the phallus and a societal tendency to value largeness in the male penis cannot he overlooked in a diagnosis of intersexuality. It is, after all, this patriarchal framework which demands that the female body a) must not possess a penis and b) is pathological if it does possess a penis.
What to do about the clitoris which threatens to assume the rightful place of the penis is made easier by falling back on chromosomes: regardless of how (en)large(d) the clitoris is, an XX karyotype will define it as a clitoris rather than as a penis. Depending on the anxiety level of the surgeons involved, the phalloclit will be remedied by varying degrees of surgical intervention ranging from partial amputation of the phalloclit to its complete exturpation. The complete removal of the clitoris is no longer a favoured mode of treatment but that doesn't mean that it never happens in current practice:
Currently few physicians perform [total] clitorectomies and when they do such operations usually follow the perceived "failure" of one of the less drastic procedures. A commonly cited reason for performing a clitorectomy after clitoral reduction or recession is the presence of painful erections and/or cosmetic dissatisfaction. In the latter case surgeons complain that the clitoris remains too large and visible. [footnote 8]
Whether or not clitorises are still completely removed or 'only' reduced or recessed, it remains valid to question who has the right to decide what a 'normal' female body looks like, or for that matter, what a 'normal' male body looks like.
The clitoris which threatens to become a penis must be made to remain a clitoris and the penis which threatens not to become a penis must also be made into a clitoris. To reiterate, it is the absence of the penis which defines the female body, in the case of micropenises it doesn't matter that there is no vagina -- it can be surgically constructed. Clitoral hypertrophy (the phalloclit) and micropenises are different case scenarios, which on an individual basis will have even greater variances, and yet the outcome of being forced into a standardized 'female' body is the destiny of each case. Why? To maintain a stable place for the phallus -- and by extension, for patriarchal, phallocratic privilege.
Through the course of treatment of intersexuality, the male body, as it is commonly understood, remains stable. What defines the male body is the penis, its size and ability to achieve and maintain erection. By removing micropenises and phalloclits, male bodies continue to be those which possess 'viable' penises. Female bodies are, of course, not stable in this equation at all. Female bodies are not defined by the presence of a uterus, female bodies are not defined by the presence of a vagina and they are not defined through the presence of reproductive ability. Vaginas can he created for those who have had their micropenises removed and if they choose to have children later they can adopt them.
This is the medical (and cultural) understanding of what female bodies do not have, and must not have: a penis. The model furthermore assumes that anybody which does possess a penis must either he designated 'male' or he surgically altered. If these options were not taken, if female bodies could run around with penises then perhaps male bodies could run around with vaginas...
Imagine the terror this scenario (a kind of gender terrorism in action), indeed a truly 'Queer Nature', must inspire in the minds of doctors who have learned so well what bodies are for (procreation and heterosexual penetrative sex). I thrill at the thought that one little phalloclit could wield so much power and cause so much anxiety -- but then I re-member my dismemberment which was/is the penalty exacted for causing such anxiety and I'm not grinning anymore.
Not that I would necessarily have kept my phalloclit. Not that I think my anger is some bizarre twist on Freud's castration theory. But I would have liked to be able to choose for myself. I would have liked to grown up in the body I was born with, to perhaps run rampant with a little physical gender terrorism instead of being restricted to this realm of paper and theory. In theory I can be many things. In theory I could have been many things. But physically, someone else made the decision of what and who I would always he before I even knew who and what I was.
1. An example of this is Testicular Feminization Syndrome, in which a person has a male genotype (i.e. 46,XY karyotype) and a body with a female genital appearance.
2. In medical practice there is no distinction made between a penis and a clitoris until a body has been declared either male or female, until that time 'phallus' is used to designate the erectile organ which could be either a penis or a clitoris. This practice is grounded in the observance of genital development in embryos which, until about the sixth week of gestation have genitalia which appear the same.
3. Note that I have made a distinction between a phallus and a clitoris because it is the designation of the phallus as clitoris which necessitates its amputation or removal.
4. CAH is one of many possible intersex etiologies.
5. I have created this term rather than describe the organ as a phallic clitoris because I don't want to describe it as an organ possessing phallic attributes -- to do so assumes that the proper place of the phallus is on/of the male. Furthermore, to describe the organ simply as an 'enlarged' clitoris assumes that all 'normal' clitorises are somehow identical (having taken the body size of the owner into consideration). These clitorises are not phallic, they are phalluses in themselves, however decidedly different from the male penis. Therefore I have retained the adjoining 'clit' to make the point that in spite of the intersexuality of such bodies, they are related on physical, philosophical and experiential levels to female bodies not deemed anomalous. I am hoping to bring to the surface, the idea that part of what informs the need to erase these phalloclits is the patriarchal anxiety over the possible phallic power of all female bodies.
6. In addition, for the XY individual who has been assigned a female sex, hormone treatment will be required throughout life otherwise there will he no pubertal activity and secondary sex characteristics will not he established (although menstruation is not likely even with hormones treatments because there is no uterus).
7. The same sentiment is expressed as "It's easier to make a hole than build a pole" by Dr. John Gearheart in Johns Hopkins Magazine, Nov. 1993, 15.
8. Fausto-Sterling, Anne, 1993b, "How Many Sexes are There?", unpublished paper prepared for The History of Science Meeting at Santa Fe, New Mexico.
Morgan Holmes is a member of ISNA, a peer support and advocacy group. ISNA can be contacted at PO Box 31791, San Francisco CA, 94131, USA. Morgan is on the verge of completing a Master's thesis on the treatment of intersexuality in Western Culture - she hopes to continue this work at the Ph.D. level somewhere in Canada. Special thanks to Trevor and Boogaloo who love me even on the darkest days.
An AIS Support Group (UK) member emailed Morgan Holmes (sometime in 1995?) as follows:
....Anyway, the purpose of emailing you was not really to ramble on about this but to ask if you could just clarify something in your "Re-membering ..." article for me. It's the sentence "Ultimately, fertility is irrelevant to femaleness while potency remains an essential feature of maleness." I understand what the sentence is conveying when read in isolation but I haven't quite made the connection with what was said in the text that precedes it.
Are you backing up what has been said already by saying that all the emphasis by medics on female fertility is futile since 'femaleness' does not depend on it? Is the word potency being used here to refer to 'physical performance' or to male fertility? i.e. are you making a comparison between female fertility and male 'performance,' or between female fertility and male fertility? Why does potency remain an essential feature of maleness? Are you perhaps saying that this is a misapprehension in the eyes of male medics?
Sorry if I'm being dense here!
Morgan replied (hardcopy letter):
Dear AIS SUPPORT UK
Thank you for your interest and kind comments on my work "Re-membering a Queer Body", enclosed is an original copy. I have also enclosed a copy of Suzanne Kessler's piece [The Medical Construction of Gender: Case Management of Intersexed Infants - see AIS in Articles/Books] from "Signs" as you requested...
...To answer your questions about the apparent contradiction in the "Re-membering" article. The contradictions are not my own, but rather those of the medical profession. Unfortunately, I think that is not really as clear as it could be in the article. To state the problem more clearly, the medical pundits continually argue that fertility in females is of paramount performance and justify genital surgeries which align genetic females with 'typical' or expected genital appearances by reduction of the phallus etc. This assumes that leaving an enlarged phallus untouched would somehow interfere with the fertility of such persons... of course we know that it does not...
I believe that the unspoken operative is that because these persons are potentially fertile as females, we should not allow them to have a physical capacity to be penetrators of their sexual partners -- the medical profession wants to ensure that genetic females will operate as receivers of the penis, and presumes that they will want to bear, indeed must bear, children because that is their genetic potential. The revision of AIS individuals who are not genetically determined to produce children as fertile women (being 'xy' at the genetic level) however, tells us that the issue of fertility is really just a ruse. What it comes down to for me is an overwhelming heterosexual imperative.
The common medical wisdom is that it is easier to build female genitals than males ones... (something I have recently argued is absolutely false). The stability of the phallus (of minimum size and function, regardless of fertility issues) is thus guaranteed to be aligned only with those 'genetically entitled' to it while the issue of fertility in genetic females and the issue of size in genetic males are used to justify the removal of large clitorises or small penises (note that these organs are likely similar in size but they are "large'"when on a female body and "small" when on a male one). The sexual potency of the genetic male is thus guaranteed in all cases where the phallus is allowed to remain. And the ruse of fertility in females is undone in cases where those who are obviously infertile are still made female.
The conflict is that of medical professionals who claim female fertility as the most important factor when they obviously don't really care in many cases. What they really care about is the stable place of the genetic male/penis alignment. I believe the logic is that whatever isn't male ('xy' with at least a 5 inch penis upon maturity) is, therefore, female. Only the male is a positive image in medicine. The female is whatever is left-over.
I hope that this clarifies the issue a little for you. The "Re-membering" piece was excerpted from a much larger body of work and lacks a good discussion of the subtleties of medical, diagnostic and procedural discourse.
Again, I'd like to thank you for your support.
Director - ISNA Canada
The discussion was then opened up to include Cheryl Chase who emailed the two other women as follows:
While I agree with much of Morgan's analysis about the way that physicians connect female with fertility, I want to point out some technical details. It is important to studiously avoid overstating our case; things are bad enough without exaggerating, and we don't want our credibility to be undermined by being caught in overstatements.
1. Virtually all intersexuality is related to anomalies in virilization, not to anomalies in feminization. Thus, female hermaphrodites have experienced more-than-no virilization (where none is typical), while male hermaphrodites have experienced less-than-complete virilization (where complete is typical).
2. That is, in an individual with ovaries, the atypical virilization is caused by some other process, outside the female reproductive system: eg exogenous androgen, adrenal androgen.
3. In an intersexed individual with testes, incomplete virilization is due to an anomaly within the male reproductive system: eg dysgenetic gonads, errors in androgen synthesis, or errors in androgen response.
4. Virtually all these anomalies in virilizing processes preclude production of viable sperm. Thus, intersexuals with testes are not likely to be fertile, no matter what medical treatment is applied.
5. Because intersexuality is not caused by the ovaries or by actions of the feminizing hormones, intersexes with ovaries may be fertile, if the virilizing process is corrected (eg, by cortisone treatment for adrenal hyperplasia).
So, what I want to say to Morgan is: Speak carefully when you accuse intersex doctors of valuing female fertility but not male fertility. While it is probably true, the fact that they try to preserve female fertility in hermaphrodites, but not male fertility, does not demonstrate it. There is rarely any potential male fertility to preserve.
I don't think I have argued that drs. are not trying to preserve male fertility... I don't think it enters the equation. What I am arguing is that they are not actually trying to preserve female fertility -- that it is just an excuse... a ruse. What I believe they are doing is (p)reserving the rightful place of the penis on the body if the male who is capable of having 'normal' penetrative, heterosexual sex.
Because culture in general, in the West that is, values fertility in the female and idealises motherhood, while it values sexual 'prowess' and phallic power in the male, it is consistent for intersex specialists to claim that preservation of female fertility is of key importance... but they are blind (I believe as a cultural symptom) to the underlying goals of their task (preservation of the penis of minimum size for the bearer of appropriate genetic structure)... and they overlook how readily they assign 'infertile' people of any genetic structure to the female sex.
I have to get going to my day job now so I'll sign off and pick up my philosophy hat again later. And mention that while this isn't precisely the stance I would take in addressing drs. face-to-face or in lit for their eyes, it is a stance that I will continue to refine in feminist journals, in cultural theory etc. Everything has a place where it can have power and be heard.
[Note from web manager:
At the time of us seeking permission from Morgan and Cheryl to put this discussion on our web site (late 1999), Cheryl wrote:
I've just had a chance to look at the page, and there's one technical detail that I would like to clarify. My correspondence that is posted there is rather old. Today, technology for assisted reproduction is advancing very quickly. Although it is true, as I said then, that most people born with testes and sexual ambiguity would not be fertile on their own, some of them could become biological parents today, using technology, and many more of them may be able to do so in the near future. For instance, men with Kallman's Syndrome (inactive LHRH, a form of hypogonadotropic hypogonadism) can now use an LH pump to restore testicular function, and many of them are fertile using this technique. Similarly, women with AIS may find in a few years that technology can allow them to become biological parents (fathers). ICSI (intra-cytoplasmic sperm injection) is now allowing many men who do not produce viable sperm to become fathers.
These facts weigh against the removal of gonads from infants on the grounds that they are "not functional." Some of the gonads which were removed a decade or two ago would be functional today, and in some cases their loss is regretted by their owners. Of course, this must always be weighed against the possibility (according to specific diagnosis) of gonadal tumors. For AIS, this seems to be pretty low before early adulthood.]