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Breaking Binaries: Medical Ethics of Intersex Individuals

Although many Americans are becoming more acquainted with gay, lesbian, bisexual, and to a much lesser extent transgender people, very few are aware of those individuals who were born outside the boundaries of male and female: those that fall under the umbrella category of intersex. This paper will begin by briefly explaining what intersexuality is and the problems surrounding the medical practices. It will rationalize how the fluidity of gender assignment is necessary so that the decision can be made by the intersex individual. Ultimately, I will assert how mandated childhood surgery is medically unnecessary as well as an unethical practice; I will advocate that personal consent is imperative in these medically non-essential procedures. Intersex is a complicated category lumping together all those with atypical biological sex characteristics into one category. There are more than seventy different conditions considered intersex manifestations (Crooks and Baur 120; isna.org). Some intersex people have mosaic genetics, the condition in which some of their cells have XY chromosomes and some have XX chromosomes (isna.org). Some intersex people have different patterns of sex chromosomes, some exhibit biological traits of male and female, some contain a mixture of male and female genitalia, and some still are hard to classify. Although a common practice, I avoid using the term ambiguous and prefer atypical to describe intersex individuals genitalia. Ambiguous infers a somewhat insulting fallacy: a persons genitals are not ambiguous to them, even if they are not quite the norm. Indeed, everybody varies greatly in their bodily constructions.

Furthermore, many intersex people do have typical female or male genitals externally; the differences are instead internal. According to the Intersex Society of North America, Girls born with XY chromosomes and complete androgen insensitivity syndrome have genitals that look pretty typically female. And some children born with XX chromosomes and congenital adrenal hyperplasia are born with genitals that look thoroughly male. Yet nearly all medical professionals agree that these kinds of conditions are intersex (isna.org). The Intersex Society of North America estimates that approximately one in 1500 or one in 2000 births result in what could be classified as intersex (Crooks and Baur 120-123; isna.org). In addition, intersex conditions can be genetic. Anne Fausto-Sterling notes in her article, The Five Sexes, Revisited, some intersex conditions are genetically recessive, thus they affect ethnic populations differently (20). A great number of intersex people do not learn of their condition until puberty or when he/she tries to have children, others never learn of their intersex body as such characteristics sometimes remain unapparent (isna.org). However, when there is an abnormality, doctors in the past (and still today) recommend sex assignment surgery rather than gender assignment for children. Sex assignment surgery refers to choosing a sex/gender for the child in an effort to normalize them through surgical modification. Such procedures often have detrimental physical, psychological, and social effects when an incorrect sex/gender has been chosen (Fausto-Sterling, The Five Sexes Revisited; Preves; Butler; isna.org). Gender assignment requires no surgery; rather infants are assigned a gender depending on which one they are more likely to identify with as they develop. This assignment has

a level of fluidity and depending on what the child wants, can be changed at any time (isna.org). This option allows for fluidity as well as personal choice in gender identity. In Preves article, Sexing the Intersexed, she draws on Lee (1994) and Kessler (1998), noting about sex assignment surgery, Families typically remain marginal in the decision-making process regarding evaluation and treatment, while the medical team retains nearly exclusive control over the situation (Preves 530). They make decisions about intersex children in an effort to uncover the true sex of the child through often unnecessary medical interventions, and they will do this without the full disclosure and consent to the parents (Preves; Butler; isna.org). Ethically, is it wrong for the medical establishment to institutionalize such practices: not only is full disclosure not given to the parents, but also the person in question (their child) has no voice or agency in the surgical normalization of their own body (Preves; Butler; Fausto-Sterling, Society Writes Biology; isna.org). Since our society insists that gender exists in the binary of female and male, we have preconceived notions about gender which leads to further confusion in intersex situations. Laurence B. McCullough, the medical ethicist working for the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, Texas echoes assertions that various forms of intersexuality should be defined as normal, intersex conditions are not diseases (though certain disease sometimes accompany different forms), and surgical and irreversible sex assignment modifications should be greatly minimized for people unable yet to consent (McCullough in Fasto-Sterling, The Five Sexes, Revisited 21). As part of our culture, we are taught to respect the opinions of the medical

establishment and believe that they have everyones best interest at heart. However, it must be the establishments duty fully inform parents of the risks of surgery over the benefits of gender assignment. Withholding cutting-edge information is unacceptable in an institution we are supposed to trust; such withholding demands our most sincere suspicions and inquiries. Furthermore, as intersexuality is a somewhat obscure subject for most folks, information must be given in depth and not lost in the medical jargon. Most Americans do not realize that their sex at birth comes down to a measurement on a ruler based upon a culturally constructed value. As Preves writes, The range for medically acceptable clitoral size is between 0-0.9 centimeters, that is, three-eighths of an inch. Any phallus larger than 0.9 centimeters is considered too large and therefore unacceptable by Western clitoral standards. Thus, according to current medical standards, the overbearing clitoris must be receded or trimmed back despite potential loss of sexual function or other possible iatrogenic consequences. Conversely, to be considered a penis within this model, an organ must be at least 1 inch long, that is at least 2.5 centimeters in length (Preves 530). A doctor and a ruler, essentially, is what determines ones sex. Infants whose developing clitoris/penis falls between the range of 0.9 centimeters and 2.5 centimeters are often trimmed or mutilated1 just because as infants, their body parts did not fall within the proper aesthetic range (Preves 530). Many intersexed people are assigned the female sex since medically it is easier (as crudely voiced) to, Dig a hole than build a pole (Holmes 169; Preves 531). While it is true that the medical establishment has had more success with constructing female
1Mutilated: ...if I may entertain the use of a charged word used to describe a similar practice in Africa often condemned by our society: female genital circumcision.

parts, the practice has serious implications in feminist theory on an ethical level and ultimately reflects sexist ideology. The idea that it is better for a child to be raised a female with partial or no ability to feel sexual (genital) stimulation nor an ability to give birth (especially since motherhood is closely tied to womanhood) than a male to be raised with a fully functioning albeit, smaller micropenis2, is deeply troubling. While the term is insulting and incorrect, I use it because it illustrates the pervasiveness of cultural standards. They inform and interact with institutions, such as medical protocols that are often credited with standing outside of those standards. The cultural problems of sexism, racism, classism, heterocentrism, etcetera still help advance those institutional constructs; the normal measurements most likely are based upon a Western, white standard that remains ignorant to multiplicities of all other ethnic populations whose measurements are different than this regulated norm. Additionally, these measurements taken at infancy are estimations which only can hypothesize growth over the following two decades of development. Often, these lengths are found unrelated (Lee). The pervasiveness of the idea that bigger is better when informing the size of a mans penis occurs at the infant level in hospitals where patients are being hacked in order to better fit into rigid sex and gender categories. Preves also points out how another cultural construct of urination helps to form these medical decisions made on the body without that persons consent: A childs genotypic makeup may be male, but unless the medical team deems the infants phallus to be of adequate size, capable of proper urination while standing, and likely to pass as (hetero)sexually normal,

2 Micropenis is the medical term describing males whose penis falls below proper range (Preves 532).

the child will likely be surgically and hormonally constructed as female (Preves 531). The general idea behind this belief assumes that males unable to urinate while standing will be ostracized socially. Still, this assumption becomes problematic since the surgical option could easily create more devastating possibilities for the individual in question. Furthermore, the heteronormative assumptions that inform these nonconsensual surgeries must be rigorously questioned. Fausto-Sterling estimates, based upon a fairly recent review of the medical literature, that one in 1000 or one in 2000 births result in some form of sex reassignment without the consent of the person on whom it is performed (FaustoSterling 20). This figure includes both intersexed and normal infants whose measurement falls out of the proper range. However, most intersexed people do not require any medical intervention as children for their physiological health (Diamond and Sigmundson; Dreger; Kessler; Preves). A feminist perspective asserts that such practices violate an innate human right. No child should have tissue removed from their body unless the procedure is required for their overall physical health (such as a urinary drainage surgery). Destroying a
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agency in a matter so intimate in order to hold everyone to a particular,

narrow beauty aesthetic while often leaving them with little or no feeling for future sexual pleasure are not feminist ideals (Preves; Butler; Fausto-Sterling, Society Writes Biology; isna.org). While sex assignment surgeries were once commonplace, with the influence of

organizations like the Intersex Society of North America, the medical field is slowly changing its views on what is best for the person in question. However, such procedures still occur based on ignorant, hegemonic assumptions of what is best for the child. As Judith Butler states in her 2004 book, Undoing Gender: Such efforts at correction not only violated the child but lends support to the idea that gender has to be borne out in singular and normative ways at the level of anatomy. Gender is a different sort of identity, and its relation to anatomy is complex. According to [Cheryl] Chase [founder and director of the Intersexed Society of North America], a child upon maturing may choose to change genders or, indeed, elect for hormonal or surgical intervention, but such decisions are justified because they are based on knowing choice. (63) There must be an element of personal choice for ethical sexual assignment procedures. As the intersex movement has gotten stronger and a number of high profile cases have made the media, more people are aware of how surgeries without consent can be extremely harmful. However, intersex politics complicate the gender discussion as they question the stiff binary of female and male categories. Since much of daily human interaction in our society relies on the binary of gender, intersex politics upset this rigid system. Butler, in her discussion writes, The intersex movement has sought to question why society maintains the ideal of gender dimorphism when a significant percentage of children are chromosomal various, and a continuum exists between male and female that suggests the arbitrariness and falsity of the gender dimorphism as a

prerequisite of human development. There are humans, in other words, who live and breathe in the interstices of this binary relation, showing that it is not exhaustive; it is not necessary (65). Such politics question why there is not an understanding of the continuum that exists between and beyond the binary of male and female and points to a falsity of this gender binary (Butler). As previously explored, there are some serious problems occurring to intersex individuals, often out of ignorance in the medical industry that we must seek to fix ethically. As it stands, namely doctors determine a persons sex/intersex at birth. It is the doctors cry, Its a boy! or Its a girl! that calls us into a gendered being, the ultimate naming act for many.

MLA Works Cited:

Butler, Judith. Undoing Gender. New York: Routledge, 2004. Print. Crooks, Robert and Karla Baur, eds. Our Sexuality. Belmont, CA: Wadsworth Cengage ! Learning, 2011. Print.

Diamond, Milton, and Keith Sigmundson. Management of Intersexuality: Guidelines for Dealing ! ! with Persons with Ambiguous Genitalia. Archives of Pediatric Adolescent Medicine. 151. (1997):1046-50. Print.

Dreger, Alice Domurat. Hermaphrodites and the Medical Invention of Sex. Cambridge, Mass: ! Harvard University Press. 1998. Print.

Fausto-Sterling, Anne. The Five Sexes, Revisited. Sciences. 40.4 (2000): 18-23. Web. Print. Fausto-Sterling, Anne. Society Writes Biology/Biology Constructs Gender. Daedalus. 116.4 ! (1987):61-76. Web. Print.

Holmes, Morgan. Rethinking the Meaning and Management of Intersexuality. Sexualities 5.2. ! (2002): 159-180. Print.

ISNA: Intersex Society of North America. Frequently Asked Questions. ! http://www.isna.org/faq/what_is_intersex. 25 March 2012 Online.

Kessler, Suzanne J. Lessons from the Intersexed. New Brunswick, N.J.: Rutgers University ! Press. 1998. Print.

Lee, Ellen Hyun-Ju. Producing Sex: An Interdisciplinary Perspective of Sex Assignment ! Decisions for Intersexuals. Senior thesis, Brown University. 1994.

Preves, Sharon E. Sexing the Intersexed: An Analysis of Sociocultural Responses to ! ! Intersexuality. Signs: Journal of Women in Culture and Society. 27.2 (2001): 523-556. Print.