Group Member Writes to Greer

A Group Member and Greer Correspond

The Member Writes to Greer

A adult woman member of the support group emailed Greer:

Dear Prof. Greer,

I have just read what you have written about AIS in your latest book, The Whole Woman, published by Doubleday, (Transworld Publishers Ltd.) and I should like to make some comments.

In any discussion of AIS you need to be aware that the condition is represented by a spectrum of phenotypes (body appearance), ranging from almost normal male at Grade 1 (Partial AIS – PAIS), to female at Grade 7 (Complete AIS – CAIS), and with various PAIS phenotypes in between; and you need to make it quite clear what you are talking about. For an explanation of the scale please refer to issue no. 6 of the newsletter/journal, ALIAS, available as a free sample download from the 'Literature/Subscriptions' page of the AIS Support Group website (http://www.medhelp.org/www/ais).

Yes, all grades of AIS result from a disruption of reproductive development in a genetically male foetus. But an individual with the complete form of AIS, who has no sensitivity at all to male hormones (androgens), will have normal female genitalia and a female body shape, and will develop breasts spontaneously at puberty (via the aromatization of testosterone from the testes to produce oestrogen). OK, the individual has XY sex chromosomes, and abdominal gonads that are testicular rather than ovarian in nature. She has no uterus and a short vagina (although many CAIS women have a vagina that is two-thirds the normal length) and no pubic/underarm hair. But after orchiectomy (gonadectomy), how different is she from an XX woman with gynaecological cancer who has had a total hysterectomy with partial ablation of the vagina? Does this unfortunate XX woman's femaleness now hang solely on the fact that some minute specks of redundant DNA in her cells are arranged in a slightly different configuration to that of the CAIS woman?

You seem to want everyone to use genetics and internal organ morphology as the sole determinants of 'gender'. In fact, a study of cell biology and embryology shows us that even at these early stages of development femaleness already equals lack-of-maleness, a concept that you find difficult to entertain and which you seem to consider only in terms of the presence or absence of a penis (a structure that isn't even in the frame at this early stage in the proceedings). Nature has determined that right from the start the route to maleness is a fragile and up-hill process that has to resist a natural inclination towards femaleness.

Chromosomes are only the starting point for the cascade of changes that result in a baby with a certain set of bodily attributes. Testes develop before ovaries. If there is a Y chromosome then the gonads become testes. In the absence of a Y chromosome the gonads become ovaries in an XX female. The job of the Y chromosome is done once the gonads have developed into either testes or ovaries in utero.

Chromosomal sex can indeed be irrelevant, in terms of external genital appearance and phenotype, and in terms of the gender identity/role a person adopts and is accepted as in society. Genital appearance is determined by the presence or absence of male hormone action, not by chromosomes. Note that even XX females owe their female external genitalia not to any female hormone action but to a lack of male hormone action. And internally the development of Fallopian tubes, uterus and upper vagina does not come about by any positive action of female hormones either, but rather as result of the absence of a testis, and therefore the absence of the male hormone called Mullerian Inhibitory Factor. This is the hormone, from the foetal testes, that kills off the primitive female (Mullerian) ducts in XY individuals.

If doctors could find a way of stopping the testes from producing MIF in a foetus known to have CAIS (and we would like them to do so) then you would have an XY woman with a uterus and vagina who would be able to carry a child following egg donation and IVF. Her situation would then be not far removed from that of the XY woman with Swyer's syndrome (XY gonadal dysgenesis) in whom the gonads never really developed at all (into either testes or ovaries) so no foetal testicular hormones at all were produced, either to curtail Mullerian development or to promote masculinization. Women with Swyer's syndrome illustrate perfectly the fact that a female body shape with female external genitalia, vagina and uterus, is the basic body form for all mankind. For maleness to be superimposed requires the active intervention of male hormones on the developing foetus, and at puberty. If this cannot happen then the default biological route is to produce a girl baby.

You criticise doctors for not "not bothering to establish chromosomal sex of newborns but.... judging according to impressionistic criteria whether the genital they are looking at is a clitoris or a penis and apportioning sex arbitrarily on the basis of this casual assessment." But if there is any doubt, doctors do evaluate these things as part of seeking the overall diagnostic picture. You seem not to have consulted any of the substantial medical literature on this subject. In your chapter's bibliography you cite only two sources relating to AIS, a newspaper article and a single medical paper: the other 17 references relate to transsexualism. The medical paper, which is a survey of diagnostic and management procedures in cases of AIS, describes quite clearly all the physical, biochemical and genetic tests carried out. I think you need to read this paper.

But how would a parent or a clinician know, at the birth of a CAIS child, that she has male chromosomes and male abdominal gonads, in view of her completely female external appearance? Only about 50% of cases of CAIS present with inguinal testicular herniation in infancy, the other 50% are not diagnosed until a failure to menstruate at puberty. Do you think that the medical system should carry out abdominal ultrasound scans and chromosome testing of all newborn baby girls? Are you suggesting that the sex police should then pronounce that babies identified as CAIS be raised as males? Bear in mind that they can never be masculinized/virilized by the administration of male hormones because of the complete insensitivity of their tissues to androgens. You are wanting to exclude XY women with AIS from the female camp yet you don't spell out what their alternative options are. Maybe you think they should be brought up, and should draw attention to themselves as an intersex category of gender? How exactly would this work in a society based on a dimorphic system? Are you suggesting that CAIS women should not dress as women, for example? And what sort of nurturing influences should the child's parents encourage to make sure that the child doesn't grow up with a feminine gender identity?

CAIS women are biologically male only by virtue of their sex chromosomes and gonads. By virtue of their external genitalia – which is what matters to most people – they are female. CAIS women don't have penises or deep voices, and do not "develop broad shoulders, narrow hips, no waist, short legs and progressive baldness and heavy facial hair" or any of the other characteristics that betoken maleness in people's everyday experience. Most of the physical characteristics that CAIS women have are ones that people expect women to have. One of the particular hallmarks of CAIS women is their very clear skin; they do not suffer from androgen-mediated skin complaints such as acne.

If chromosomes and gonads are so important in determining who is a woman and who is not, how is that our support group is quite often contacted by CAIS women in their 40s, 50s and 60s, in many cases married, who due to a policy of medical secrecy in the past have had no idea of their status in this regard until catching sight of their medical notes or being told inadvertently by a new doctor?

When does a clitoris start to become a penis in your view? If size is the main criterion then XX women are nearer the front of the queue for 'a small penis' than CAIS women. CAIS individuals never have any `penile development' as you put it, but have in fact a clitoris that is smaller than that of an XX woman, because the genital tissue of XX women, unlike those with CAIS, is sensitive to the (relatively small amounts of) androgens their bodies produce. And in any case, for a woman to have a clitoris that is larger than the average is not an illness any more than it is for a man to have long hair. Genitals are for human intimacy and pleasure, not just for reproduction, or for social approval.

You also seem to hint that the complications of surgical vaginoplasty in male-to-female transsexuals and in AIS somehow of itself validates an essential maleness in these individuals (as if by some sort of innate rejection by XY bodies of an imposed feminization)? And yet exactly the same complications would occur in an XX woman with Mayer Rokitansky Kuster Hauser (MRKH) syndrome who is born with ovaries but without a uterus or vagina. Are these women allowed entrance to your exclusive female club, I wonder?

I think we have to be clear about how we are using words like 'sex', 'gender', 'female', etc. To me, 'sex' is a biological attribute – some people break it down into genetic sex, gonadal sex, hormonal sex and genital sex. These are reasonably precise. But when you move into the much vaguer psycho-social arena and start to describe the whole person using terms like 'a female', 'gender', and 'woman', which can refer to biological and/or social characteristics, you have to define what you are covering by these terms. When you talk about gender, for example, what do you mean? I think you are using it to mean some aspect(s) biological sex. To me, gender is largely a socially-constructed attribute.

There is also the confusion over the terms 'intersex' and 'ambiguous genitalia'. My understanding is that intersex is a biological state in which there is a degree of discordance between a person's genetic sex and their bodily sex (including genital appearance). A CAIS woman is, by this definition, intersexed at a biological level. But she most certainly does not have any masculine aspects to her appearance, let alone ambiguous genitalia.

If you are attempting to write any sort of serious treatise on something as complicated as reproductive biology, AIS, and its consequences, you shouldn't really rely on magazine and newspaper articles a source of information (and you seem woefully uninformed on the biological/medical side of all this). Journalists invariably misunderstand the biology involved and make misleading statements or quote things out of context. You risk magnifying this by lifting such quotes and putting yet another gloss on them. Even your research amongst the daily newspapers seems not to have been too thorough. The British media were not alerted to the existence of AIS by the Guardian and Cosmopolitan in 1996, because the Guardian published a piece on AIS in 1995. And in any case, the Independent, The Daily Mail and 'Take a Break' magazine all ran articles on AIS in 1994.

All the quotes you used from the Guardian and Cosmopolitan articles related to AIS women and not to PAIS men or those with ambiguous genitalia. As it happens, Beverley de Silva was correct in stating that "Biologically they are male; in every other way they are female." She is acknowledging the biological reality of their early embryological history (and that's what it is, history) together with the reality that they are women, in their own eyes and those of society. Quoting Simone Cave's words out of context as you have done makes it seem that she, like you, is blurring the lower grades of PAIS with CAIS (in which there is never any ambiguity in genital appearance or, usually, in gender identity – and it seems to be these attributes, and not genetic/gonadal sex, to which she is referring). If one reads the whole of the Cosmopolitan article it is abundantly clear that although she uses the general term 'AIS' her statement brings to an end a discussion of the complete form of AIS. Her next sentence, after the quote, introduces the concept of PAIS, and the ambiguous genitalia that can sometimes accompany it, depending where on the grading scale the individual lies.

The person referred to as H____M______ is a member of our group; and she found out, after participating in the Guardian article, that she does not have AIS after all but is an XX woman with Mullerian dysgenesis. But we are not banishing her from our group on the grounds of not being intersexed, because the similarities we share are much, much greater than any differences that might divide us. Had her parents treated her as a boy, as you seem to be advocating for AIS girls, she might be rather confused by now.

Many of our members have adopted with enthusiasm the symbolism of the orchid (orchis = testis in Greek) and are now making a point of using the medical term 'orchidectomy' in front of doctors rather than the evasive, wool-pulling 'gonadectomy'. This is a way of reclaiming the male aspects of their origins from behind the dark curtain drawn by the doctors between what they write in the medical literature and what they discuss with parents and patients. One of the main aims of our support group right from the start was to expose the biological facts about AIS to the world at large and to show that the notion of XY women with testes was possibly more of a threat to the male-dominated medical establishment than to many young patients (once they've been given all the facts in a supportive way, have had time to adjust to them and have met other AIS women). Professor Howard Jacobs, whose comments you criticize, is actually one of the more forward-thinking clinicians in this regard and is therefore making a valuable and welcome contribution to humanity by informing AIS girls/women of the aetiology of their condition, yet stressing and validating their female destiny. Yes, the mechanism by which AIS comes about is a biological failure to masculinize but those at the higher end of the AIS scale will continue to be the women that they are.

Have you met any AIS women? We would very much like to welcome you to one of our group meetings. A number of members have also said in the last few days that they would like the opportunity to appear on TV with you to discuss these issues. Would you be willing to do this?

Yours sincerely

[________]

Greer's First Response

Greer responded by email as follows:

One of the frustrating aspects of the furore over my discussion of press items about AIS individuals as women in men's bodies is that virtually none of the authors of the letters and e-mails has bothered to read any more of The Whole Woman than those two pages. I receive hundreds of letters a week that relate to the other 348 pages and to the situations in which XX women both wombed and wombless find themselves. I cannot deliver myself up to this (extremely vocal) minority discussion. By all means disagree with me, but, as you also disagree with each other, you might get further if you worked on your own basic assumptions about what male and female are.

Here, for argument's sake is my philosophical position. It is only one position among many possible positions, but it is consistent and it underlies my whole argument, as distinct from the snippets that interest you.

Sex and gender are not the same thing. Males may be anything from ultra-feminine to ultra-masculine, as may females. The contrast between ultra-masculine and ultra-feminine is many times greater than the contrast between male and female. However feminine a male may be, he may not be female. However feminine the gender role he chooses to pay his is not female experience. Femaleness involves a biological burden that he cannot choose to carry, any more than he can choose to be of a particular race or carry a particular genetic disorder.

Medical practice is not only predicated on a narrow identification of sex with gender, or femaleness with femininity, it is also wedded to a denial of intersexuality as a destiny, though it is also quite willing to assist individuals who wilfully extirpate all sexual characteristics in a struggle to transcend both sex and gender. It is far more useful for AIS support groups to decided what they are going to do about doctors' lies to AIS parents and about disambiguation surgery performed on newborns than to try to convert me by a storm of words either to an acceptance of XY individuals as female or to an identification of sex with gender.

You may reproduce this letter on your website, in the hope that some of those who visit it will understand that my purpose is to assert femaleness as a positive condition and a distinct destiny regardless of the degree of perceptible femininity or masculinity.

Professor G. Greer.

Greer's Second Response

Almost simultaneously, Greer sent another reply to the group member by snail mail:

Dear _______,

Androgen Insensitivity Syndrome is not my subject; two of the 350 pages of my book The Whole Woman refer to it. My concern is with the steady devaluation of the word 'female' to mean anything that looks like or can pass as a woman. All I am trying to say is that there is more to it than that. You ask if I think that all newborns should have their internal organs examined. You do not ask if I think a routine test should establish their chromosomal status - as clearly should have happened in the case of H____ M____.

In the very first sentence of Complete Androgen Insensitivity Syndrome [parent/patient booklet that the group member had sent to Greer] Warne identifies all AIS individuals as daughters, even though later on he will divide PAIS individuals into girls and boys purely, apparently, upon an impressionistic assessment of the degree of external genital development. The idea of 'girls' born with testes and no wombs may be acceptable to men; accepting it certainly assists the acceptance of 'transsexual' but otherwise normal XY individuals as women in men's bodies. It is precisely the denial of chromosomal sex that I won't countenance, partly because it is having the effect of treating the female sex as a grab bag for all anomalies, thus implying the [that] femaleness iteself is an anomaly.

There is a growing movement to recognise intersexuality as a destiny and sex of its own, which is itself part of the struggle to relax the rigidity of gender roles and dispel ubiquitous gender dysphoria. AIS individuals, instead of being treated as sick women, and dosed with steroids (oestrogens and progetsogens), could be accepted as healthy intersexuals and allowed to exhibit the characteristics that doctors seek to obliterate in the interests of gender uniformity. It would also mean that babies exhibiting partial penile development would not be routinely mutilated and equipped with fake vaginas, which is and should be a matter of concern to AIS support groups.

Femininity is accessible to both sexes, just as masculinity is, but femaleness is a special destiny in its way as intersexuality is. I am trying to invest femaleness with its own positive value, which is not helped by characterising all failed males as female. It is not a belief in equality but pure misogyny that controls this mindset; incomplete females are not offered the option of becoming honorary males. Undergoing oophorectomy [removal of the ovaries] will not make me a man though I do go bald and grow hair on my chin.

Yours faithfully,

Professor G. Greer

The Member Responds

The group member responded, as follows:

Dear Prof. Greer,

We are pleased that you honour this discussion with the accolade of being a 'furore'. I'd like to answer some specific points (in italics) from your recent email and letter:

....[only] two of the 350 pages of my book The Whole Woman refer to it [AIS].... So does this absolve you from 'doing your homework' before ranting about something in a public forum?

You do not ask if I think a routine test should establish their chromosomal status.... I did ask this. Please re-read my letter.

....as clearly should have happened in the case of H____ M____.... Why should it have happened? It wouldn't have made a scrap of difference - to her completely female appearance, to her upbringing, her gender ID, sexuality or role in society. She has never had ambiguous genitalia and has always had a vagina.

....Warne identifies all AIS individuals as daughters.... Yes, because the book is about the complete form of AIS.

It is precisely the denial of chromosomal sex that I won't countenance.... Well what about the XX individuals born with a normal sized penis (see Dr. Charmian Quigley's letter). Are you saying that they are women by virtue of their chromosomes?

There is a growing movement to recognise intersexuality as a destiny .... Yes, there is; amongst some people with ambiguous genitalia - but not amongst the majority of CAIS women, where that is not the case.

....instead of being treated as sick women, and dosed with steroids.... Current medical wisdom is that AIS women should have their gonads (testes) removed at some point after puberty because of a small but real risk of cancer in their abdominal testes. If they don't then take oestrogen-based HRT, they risk osteoporosis and have an increased risk of heart disease.

....allowed to exhibit the chracteristics that doctors seek to obliterate.... CAIS women have no such characteristics. Their genitals look like those of XX women (with a clitoris that is smaller, if anything, than in the latter).

....babies exhibiting partial penile development would not be routinely mutilated... should be a matter of concern to AIS support groups.... It is; where babies at the middle/lower end of the Quigley grading scale are concerned.

Femininity is accessible to both sexes... Yes, it is. I have not hitherto mentioned femininity in my argument. I am concerned with gender, i.e. being a woman in society, and not with the question of superficial feminine or masculine behavioural traits or affectations.

Undergoing oophorectomy will not make me a man.... This seems like an irrelevant no-sequitur. AIS women do not undergo orchidectomy in order to feminize them, or to prevent some hypothetical masculinization (remember they are insensitive to testicular androgens - to androgens from any source) but because of a cancer risk.

You talk about your 'philosophical' position but you fail to appreciate that gender is not merely a philosophical entity but something that exists in society.

Imagine the case of a middle-aged, married CAIS woman who has never had periods and has been told in her teens that she is infertile, but has never had any reason to doubt her female gender. A new GP lets slip the fact that her notes state that she has XY chromosomes and has a condition called Androgen Insensitivity Syndrome. What are you proposing she do at this point?

You still have not answered our basic question as to what someone with the complete form of AIS is supposed to do, on a practical level, according to your 'philosophy'. Does she not dress as a woman, not go to a girls' school, not use women's toilet facilities, not be allowed to put 'F' on application forms........?

Yours sincerely,