Intersex, Part One: Biology, Medicine, and Society

There are two sexes within the human species that are opposites, right? And they’re determined by the configuration of a person’s chromosomes or what their genitalia look like, right? You are either male or female, and either way it’s all really simple and clear. Or is it? Nah, come on, nature is never that boring. I am, of course, talking about intersex.

Let’s first take a look at the biology of intersex, and then I’ll move on to some social and ethical aspects.

There’s a wide variety of anatomical states that are considered intersex. Some are clearly rare and detrimental enough to count as genetic defects and others are neither disabling in any way nor uncommon enough to be anything other than normal variations of human sex development. In fact, the latter is the case for the majority of intersex people. In humans and non-human animals the term intersex describes the presence of a wide range of genetic, hormonal and/or physical features considered typical of both males and females in one person, or the absence of such clearly defined features. Intersex is about anatomy and has nothing to do with a person’s sexual orientation. It’s a scientific term and not a gender identity of any kind. It’s also unrelated to transsexuality. Estimates on the prevalence of intersex range from 1.9% (Anne Fausto-Sterling, 2000) to 4% (various authors) of the population.

Besides the average XX-female and XY-male, there are XY-females and XX-males. There’s also a whole bunch of folks with chromosomal combinations different from the standard XY and XX: XO, XXX, XXY, XXXY, XYY, XXYY, and a couple of others. Genitalia and reproductive organs can also come in a variety of shapes. For starters, there are typical male or female looking genitalia, though at which point “typical” is typical enough for it to be considered, well, typical, is debatable.

Besides those, there are many other combinations of male and female plumbing. Ambiguous genitalia range, among other combinations, from a bigger than average clitoris or smaller than average penis over alternative placements of the urethral opening in males (from slightly farther down the glans over it being somewhere along the shaft to it being below the penis on the body wall; this is usually not painful or deleterious in any other way and mild cases are present in 45% of the male population) or fused labia with a partial empty scrotum and a uretha within the clitoris and the presence of a uterus to – let me take a breath – so called true hermaphroditism, where a person possesses both testicular and ovarian tissues simultaneously. Functioning of both types of gonadal tissues is so far undocumented in humans. So much for the myth that intersex people can knock themselves up. The majority of intersex people have no visible external physical differences in comparison to non-intersex people.

The first thing parents want to know is usually whether their newborn is a baby or a giraffe, er, male or female. (I just wanted to see whether you’re still with me.) The birth of a child who isn’t at any immediate health risk but has ambiguous genitalia is still considered a ‘social emergency’. Not a medical emergency – a ‘social emergency’. Nonetheless, or more likely just because, the medical profession prefers to go to town with an army of surgeons, endocrinologists, and geneticists in the name of restoring an artificial binarist, heteronormative order for the benefit of the parents and so the child can be raised in a sex-typical fashion. You know, because gods beware of the gender binary not being enforced strictly on every single child in this world or parents having to explain to their children how sex and gender work. Homophobia also plays a part in this. According to reports of doctors, parents who have been told their child is intersex frequently react by asking “Does that mean my baby will be gay?“

This ‘social emergency’ entails surgeries (notice the plural) and often lifelong hormonal treatment, but before that doctors determine whether to aim for a typical male or female look, depending on the cause and type of intersexuality. However, this often can and does go wrong in many ways, as doctors work off the assumption – yes, it’s merely an assumption – that you can determine the “true sex” of an intersex person if only you look closely enough. Then there’s still a whole slew of other problems. Mind you problems that aren’t inherent in intersex, but are created by doctors and society.

In patients with congenital adrenal hyperplasia, for example, a condition that leads to different degrees of virilization in females and can result in intersex but is, except for some types, harmless, an enlarged clitoris may be shortened by cutting out a piece of its visible body in the middle and sewing the top back on. Some doctors, such as Dr. Dix Poppas in New York, test the surgical outcomes by having children as young as four subject to sexual stimulation to assess whether the “resculpted” clitoris can respond as demanded. Not long ago, all of the clitoris that could be cut out actually was cut out, as doctors mistakenly thought that female orgasm is produced in the vagina and the clitoris was useless. Once again sexual sensation is sacrificed on the altar of subjective normalcy.

In some female assigned children, a vagina is surgically created. A neo-vagina is created and maintained with the same procedures as in transwomen. As surgeries are performed as early as possible, even babies will have to suffer through painful regular vaginal dilations. This means exactly what it sounds like. A parent has to insert a dilator into the neo-vagina to keep it from closing again, as the body basically treats it like a wound. This must at first be done daily, then weekly, and must be continued by the child for the rest of their life.

The fact is that at least 20-50% of all surgeries ultimately result in a loss of sexual sensation. “From studies conducted in the UK with limited funding and a small group of participants, it has been found that intersex people who have been subjected to surgery have sexual intercourse less frequently and that when they do, they enjoy it less. Other research by Drs Minto and Creighton show that intersex children fare as well if not better without surgery than those who are subjected to it.“ (OII, 2012)

And then there’s also gender identity. There’s virtually no way of knowing the gender identity a child will grow up to have. In cases where doctors choose to assign a baby one sex but it grows up to identify as another, they might be responsible for having created a transsexual. The child could otherwise have well been content with their physiology as an adult or, if they had grown up to want to be assigned male or female, would’ve at least had to go through treatment only once in their life and of their own accord.

In a part of the Dominican Republic, where one type of intersex is especially common, they mostly stick to an approach from which our doctors could learn as well and the only one that can be considered ethical: Intersex children aren’t subjected to medical procedures they’ve never had a chance to consent to, but instead grow up in a holding pattern until they feel ready to announce their identity.

Stay tuned for part two on intersex, in which I will take a look at intersex in relation to marriage equality.

Sources:

Evolution’s Rainbow – Diversity, Gender, and Sexuality in Nature and People by Joan Roughgarden

What Is Intersex?

Intersex Genital Mutilation – IGM: The Fourteen Days of Intersex

Intersex – Wikipedia

True hermaphroditism

____________________________________________________________________________________________________