NOTE:
This paper discusses the surgical and medical management of
intersexed children in terms of a relationship of violence in
which the intersexed infants/children are completely
disenfranchised, it highlights the similarities between
traditional practises of female genital mutilation and genital
'reconstructive surgery', fleshes out tensions around complicity
in the genital mutilation of intersexed infants and children, and
views homophobia as a motivating factor in the management of
intersexed bodies.
"Sunna... involves the removal of the prepuce, or hood of the clitoris or the removal of the entire clitoris"[Woods & Clouse,1993, 3].
With pen and ink a U-shaped dorsal incision was marked out on the clitoris with the apex at the base of the pubis. With the glans and clitoris under tension, the U-shaped incision was carried out around the dorsal aspect of the clitoris to the glans. The dorsal hood of skin was then removed and heavy dexon sutures were placed through the base of the crura of the enlarged clitoris. The redundant corpora was then excised dorsally. ...The glans was then recessed into the infrapubic area with several fine dexon sutures and then the skin approximated as a new clitoral hood with interrupted fine dexon sutures [ M. Holmes, Med. File, March 18, 1975]."Intermediate circumcision... is the removal of the clitoris, all or part of the labia minora and sometimes part of the labia majora"[Woods & Clouse, 1993, 3].
A midline vertical suprapubic incision was made, deepened down to expose the peritoneum which opened in the usual fashion. ...External genitalia were then exposed and incision was made around the base of the clitoris. This was dissected free from the surrounding tissue as far back as the division of the corpora where it was clamped, divided and stump ligated. ...Skin edges were approximated using chromic cat-gut [BGS., Med. File, January 23,1958].It is frequently taken as given that female genital mutilation [1] is an act of violence which deprives women of sexual function and pleasure, severely threatens the health of young girls and causes complications in labour that can result in the death of mothers and loss of fetuses.[2] Insofar as FGM endangers the health and lives of those to whom it is done, and because it is done to dissuade sexual activity in women, FGM certainly meets the required defining features of interpersonal violence as they are laid out by Stanley French: "[violence is used] to injure, control or intimidate... ...violence is any act that causes the victim to do something she or he does not want to do, or prevents her from doing something she wants to do, or causes her to be afraid" [1993, 3].
To satisfy the given definition according to French, it is merely necessary to point out that at some instance, a single doctor will wield the scalpel that is used to slice off the sexual, erectile, genital tissue of an intersexed (hermaphroditic) child. However, I want to stretch the limits of French's definition somewhat by insisting that interpersonal violence does not have to be seen only as a one-on-one act, that indeed teams of doctors in large institutional settings, within the context of a larger social web, are perpetrators of interpersonal violence as soon as they set out to diagnose and treat intersexed children.
Doctors who specialize in the treatment of intersexuality are most often male: of twenty prominent surgeons or physicians in the field, three are women.[3] Patients are most often assigned female and have their genitals surgically mutilated in order to be brought into line with that assignment.[4] On occasion patients diagnosed as male "pseudo-hermaphrodites", who have a penis of at least minimum acceptable size, may not be assigned female, but as two examples in this paper will show, the health risks caused by surgical intervention used in such cases are significant and debilitating.
Patriarchal misogyny is operant in any decision to reconstruct the genitals of a child diagnosed as intersexed, regardless of whether the child will be assigned male or female. This misogyny is apparent in the perpetual justification for amputating or removing the (en)large(d) phalloclit of a female pseudo-hermaphrodite: the possibility of fertility in female 'pseudo-hermaphrodites' is viewed as more important than the debilitating nerve and tissue damage which results from genital surgery. It is apparent when patients with androgen insensitivity (Chromosomally 'XY' with apparently female genitalia) also have their phalloclits amputated or entirely removed: in such patients the phallus is deemed too small to be 'properly' male but too large to be appropriate for a woman. Finally, it is apparent when a genetic male, with functioning testes and a fully formed penis is diagnosed as 'intersexed' because he has a hypospadic (i.e. short) urethra which exits from 'the female position'. All patients in these examples are surgically mutilated because they are either a) genetic females for whom reproduction and 'normal' appearance are considered more important than sexual function/pleasure or b) genetic males whose genitals have been 'polluted' by 'feminine' sexual characteristics (i.e., the short urethra, or a phallus considered so small that it must be made into a clitoris through amputation). That the mutilations are carried out by surgeons makes them no more legitimate than if they had been carried out, for example, by Egyptian plumbers [5] or Somali mid-wives.
Interpersonal violence does not necessarily have to be grounded in 'acts of violence ' per se . That is to say, violence is conventionally understood in terms of acts of aggression i.e, beatings, bullying, torture, sexual assault, emotional abuse. In this paper I am suggesting that the term "violence" be applied to any situation in which one person or group is using power and privilege as a means to control, limit or altogether deny the freedoms of another person or group of people. In the specific parameters of this paper the individuals tend to be infants who are forcibly sexed as females.[6] The group is classified as 'intersexed' by the medical system which exerts its power and authority to impede the freedoms of both intersexed infants/children and their families.
In the case of the medical mode of treating intersexuality, there is an abuse of power at many levels: doctors routinely mislead parents as to the nature of their child's condition, revealing only that the genital appearance is ambiguous because "nature hasn't finished the job" [Hendricks]. The kinds of tissue removed and the extent of the removal are also not fully disclosed, the term 'clitoral recession', for example, does not clearly indicate that any portion of the tissue will be removed/amputated and yet, in practise, that is what the surgery entails. Invasive surgeries are thus carried out on children who are either pre-linguistic or unable to speak for themselves as legal minors. Decisions about the future of intersexed children's sexualities are made based on an assumption that children are property and parents thus submit bodies (which are indeed not their own) to medical and surgical modes of "management" which they do not fully comprehend. In addition to the obvious violence of imposed pain and loss, the very objective of treatment, which seeks to impose silence and sexual restrictions, is emotionally violent.
The imperative to silence intersexed children can be seen in medical texts which repeatedly advise against fully disclosing a patient's history to her once she has reached maturity. Indeed, they urge doctors to 'reassure' a patient of her normalcy. The medical establishment assumes, from the outset, that a patient will not be able to tolerate the 'truth' about his/her intersex status.[7] Thus a patient whose testicles are removed and whose clitoris is amputated because she has Androgen Insensitivity [8] will be informed that she is sterile because her ovaries didn't function well, not that she is sterile because she has no uterus and never had ovaries in the first place.
To privilege Western medical science/knowledge above traditions of developing nations' is to be complicit in the mutilation of thousands of intersexed children in North America. While it may be tempting to claim that doctors have a more 'objective' and, therefore, scientifically accurate base from which to operate, [9] the following example shows that what is known about intersexuality is as subjectively b(i)ased as what is known about female sexuality.
From my birth until the surgery, while I was Charlie, my parents and doctors considered my penis to be monstrously small, as well as lacking a urethra. ...Then, once the intersex specialist physicians had announced that my "true sex" was female, my clitoris was suddenly monstrously large, all without changing size"[Chase, forthcoming, n.p.].Literature and publicity on FGM repeatedly state that genital mutilation of females is most prevalent in cultures which value virginity in females; the object of the mutilation is to control female sexuality. In her essay "Reproducing Medical Violence Against Women," Jessica Bradley indicates that clitorectomy was a practice of 19th Century Western medicine, used to control women's sexuality [1994, fn.1]. In Complaints and Disorders, Barbara Ehrenreich and Dierdre English indicate that "The last clitorectomy we know of in the United States was performed twenty-five years ago on a child of five, as a cure for masturbation"[1973,34]. Semra Asefa writes "FGM was also practised... in Canada, England and the United States as recently as the 1940's to treat masturbation... and other female 'deviances',"[1994, n.p.].
Information on FGM, by repeatedly stating that clitorectomies in the West ceased forty to fifty years ago, promotes the myth that FGM would only be practised in 'modern' Western Culture by immigrants from cultures which routinely carry out FGM as a religious/traditional rite. This is a culturally imperialist view which relies heavily on the notion that the West is, for all its problems, scientifically superior and therefore, more concerned with women's health than those countries in which FGM is a traditional practise.
The myth that clitorectomies have ceased in the West is itself a form of violent foreclosure. As a commonly cited 'fact' it denies that clitorectomies are a common medical procedure, if not a common traditional practise, in the West. Furthermore, this myth is convenient for those who suffer from a will to ignorance rooted in homophobic and xenophobic values, values which circulate around a binary of normal vs. sick sexuality, sexual practise and sexual identity, values which make it easy to "scapegoat immigrants from certain nations"[Reynolds, 93].
According to Ehrenreich and English, Asefa, Woods and Clouse and a recent Vision TV panel on FGM,[10] the common motive behind FGM practices, regardless of geographic and/or cultural location, appears to be rooted in a religious and/or cultural mandate to control/deny women's access to their own sexualities. This observation is a point well-taken. However, the prevalent claim that clitorectomies ceased in the West in the 1940's or 1950's at the latest is, as indicated above, an invested mistake. As proof of this inaccuracy, I redirect the reader's attention to the dates of the post-op reports which open this paper: 1975 and 1958 respectively.
As indicated in its reference, the first medical example of clitorectomy comes from my own file, the post-operative report is about my body and what was done to it. My surgery was performed at Sick Children's Hospital in Toronto by a pediatric urologist who continues to perform t/his work at John's Hopkins University Medical Centre.[11]
The post-op report for 'BGS' indicates the her surgery was performed in 1958 when she was 18 months old. Textbooks in pediatric Gynecolgy from the eighties and nineties continue to advise the same procedures indicated in the files which open this paper.[12] However, the complete clitoral extirpation done to 'BGS' is usually only carried out after a partial clitorectomy has been performed and judged inadequate.[13]
Although BGS has a very large scar on her abdomen running from the navel to the pubis, no labia minora and a pad of scar tissue where one would expect to find a clitoris, her doctors and family refused to ever tell anything about her surgeries except to say that she'd had exploratory surgery during an appendectomy. In my own case, although I was seven when my surgery was performed, and quite attached to my body as it was, no one ever explained to me why I was going into the hospital. Furthermore, what happened to me there was never spoken about in my family again until I forced the issue while writing my master's thesis on intersexuality.
These examples indicate abuses of power in which silencing and erasing pan-sexual potential are the dominant imperatives. But if it is relatively clear that doctors are misusing their power in these cases, the relationship and responsibility of parents to their intersexed children is more clouded. Because parents initially receive inadequate and/or misleading information, they tend to see themselves as acting in their children's best interests. Therefore it is important to consider the ways in which the medical system is able to exert enough power and control to lead parents to believe themselves to be acting "in good faith" when, in fact, they are sentencing their children to lives of physical dysfunction and emotional trauma.[14] One of the more powerful tools available to medical 'experts' who perform genital revisions is the promise made to parents that their children will become adults with "normal sexual function" [M. Holmes, Med. File, January 23, 1984]. This promise is repeatedly alluded to in the medical files and literature dealing with intersexuality and it implies that if the child does not have reconstructive surgery then his/her adult sexual function will be abnormal.
Dr. Melvin Grumbach, of UC San Francisco claims that it is not possible to envision a society that would be willing to accept intersexuality and for parents it comes down to this: "They don't want their kids to be different. ...in the days before surgery...there were a number of suicides [among intersexuals]" [Alvarado, 1994, 18]. In the same article, Fausto- Sterling responds to Grumbach by proposing that a different society is not impossible -- that at the very least surgery could be delayed until intersexed children could make their own decisions , "The medical world is not helpless. They're not saying 'We can't.' They're saying, 'We won't.'"[Ibid.,19].
I am arguing that concern for the intersexed child's well- being is a ruse which obfuscates scientific and cultural investments in maintaining clear distinctions between normalcy/health and deviance/pathology. Intersexed bodies blur distinctions between the two recognized sexes and call into question the oppositional categories of sex as they are constructed in Western, heterosexist culture. Only by limiting the possibilities to two distinct sexes can a predominantly homophobic culture posit that heterosexuality is "normal/natural" and not a constructed imperative.
In the 19th century practitioners of the growing discipline of statistics developed the idea of the normal [distinguished from the natural], as that which occurs with greater frequency. From this viewpoint, males and females are normal while intersexuals, natural as they may be are not. Medical practitioners fused the notion of the abnormal with that of the pathological--something harmful, to be controlled. ...The knowledge developed by the medical disciplines empowers doctors to maintain the normal by changing the hermaphroditic body to fit as best we can make it into one or the other cubby hole [sex](my emphasis)[Fausto-Sterling, forthcoming, 63].
At what price is this promise of normalcy fulfilled and is it indeed fulfilled? I am personally acquainted with Cheryl Chase, the founder of the Intersex Society, as with myself, her surgery may have actually produced her suicidal feelings: "Chase thought...if I was going to do do such a messy suicide, slicing up my throat [with a razor], I would do it in one of the doctor's offices. So they could see it," [Ibid., 18]. This is not to imply that being left alone would be untraumatic; clearly we live in a culture that does not tolerate difference well. It is not my argument that surgical revision should never be allowed, but rather, that by waiting until the child's body has matured physically, surgery (if desired by the patient) would yield better results.
Promoting surgery in infancy as a guarantee that the intersexed child will mature to be non-suicidal and happy is clearly wrong. A letter to ISNA from an intersexual I know only as "monster"[15] states:
I pray that some day I will have the means to repay, in some measure, the American Urological Association for all they have done for my benefit. I am having some trouble, though, in connecting the timing mechanism to the fuse"[ISNA, personal letter, Nov. 14, 1993].I have little direct knowledge of this person's medical history but it appears, from his description of his surgeries and the fact that urologists did them, that he probably had a hypospadic, or "female", urethra -- that is, one that exits the body closer to the base than to the tip of the penis. This individual was subjected to multiple surgeries over a three year period. Complications which result from such 'corrective' surgeries can be: fistulas (holes) inside the constructed and elongated urethra, there can be infections caused by continued hair growth inside the constructed tube; severe nerve and tissue damage;[16] and chronic bladder infections. Additionally, it may become frequently necessary to drain the bladder by using a catheter because the constructed urethra can constrict, making urination difficult or impossible. All this because these 'feminized' males would otherwise have to sit to pee.
To further contradict Grumbach's assertion that the psychological health of an intersexed patient is dependent on surgery, consider the following results from Fausto-Sterling and sexologist Bo Laurent:
... [In] 70 case studies of adolescents and adults who grew up with visibly anomalous genitalia. ...only one of the cited examples was an individual deemed potentially psychotic, and the the potential illness was connected to a psychotic parent and not to sexual ambiguity. ...Even proponents of early intervention recognize that adjustment to unusual genitalia is possible. Hampson and Hampson...wrote 'The surprise is that so many ambiguous-looking patients were able, appearance notwithstanding, to grow up and achieve a rating of psychologically healthy, or perhaps only mildly non-healthy [Fausto- Sterling, forthcoming, 74].
I would add to this statement that being 'mildly non- healthy' is probably an accurate description of most people at one time or another and, thus, may be completely unrelated to the anatomical appearance of the patients in the Hampsons' group.
Against this back-drop, Grumbach's apocalyptic which imply the inevitability of suicide in unrevised intersexed patients seem ludicrous. The individual who underwent the seventeen surgeries has stated that the next time his urethra requires surgery, he will have his penis removed. Of all ISNA's members, only one person has reported being reliably responsive at the physical level of sexual activity and it is significant that her surgeries were performed after the onset of puberty. From these accounts it seems clear that, in fact, 'normal sexual function' is not accomplished -- the medical treatments are only capable of augmenting the trauma of difference while in the pursuit of "... the best cosmetic effect"[(my emphasis)M. Holmes, Med. file, October 25, 1974 ].
By now, readers may be thankful if they have never been directly associated with an intersexed child, thankful not to be faced with the limited choice available within a medical framework. But denying any personal interest in social norms which prohibit sexual difference, places all responsibility for the mutilating treatment on the shoulders of surgeons who specialize in the reconstruction of intersexed genitals. Fausto- Sterling argues that the surgeons do no operate in a vacuum but within a larger social climate which adamantly refuses to recognize homosexuality as legitimate:
But why should we care if a "woman," defined as one who has breasts, a vagina, uterus and ovaries and who menstruates, also has a clitoris large enough to penetrate the vagina of another woman? Why should we care if there are people whose biological equipment enables them to have sex "naturally" with both men and women? ...Society mandates the control of intersexual bodies because they blur and bridge the great divide [Fausto- Sterling,1993a, 24].In the desire to produce a sexually 'normal' child, is the desire to ensure heterosexuality. A desire to be fulfilled, as I have pointed out, at any cost to the intersexed child.
In my experience, parents confronted with the anger and grief of their adult-intersexed-mutilated children want to be relieved of any accountability for the cost of their attempts to make us sexually 'normal'. They want us to congratulate them for any resistance they may have shown, or to direct all of our anger toward the medical establishment. However to thus relieve our parents would be to inadequately interrogate the reciprocal relationship of parents and surgeons who do not challenge, but rather, accept heterosexist norms which mandate the erasure of intersexed body-types. And while parents of intersexed infants deserve some sympathy for being misled by the medical 'experts' I want to point out that in this case the old adage, "If you aren't part of the solution, you're part of the problem," holds true. Societally sanctioned homophobia is partly to blame for the invasive, violent and damaging treatment of intersexuality. When parents sign consent forms , allowing doctors to remove the erotogenic tissue of their children, they are willingly following a heterosexist requirement that humans live as either male or female. The cost is paid in terms of physical function and sensation, in terms of self-image and self-esteem and it is paid by the intersexed children.
Parents need to be made accountable for their failures to educate themselves about what surgeries will do to their children's bodies and for easing the "private distress [intersexuals] cause the parents,"[Angier, D8] by having their children mutilated.[17]. By leaving these aspects of treatment unexamined, the multiple levels of manipulation and control of intersexed children remain obscured. It is very convenient to insist that parents are making difficult decisions under imperfect conditions. However, as adults entrusted with the health and care of children, parents are responsible for educating themselves about proposed medical treatments. To sign consent to treatment on the assurance that surgical revision will produce a sexually 'normal' child leaves one open to charges of homophobia. If, as a parent, you would rather that your children were straight than gay or lesbian, even if you're not against gays and lesbians (as long as they're someone else's children) then you are implicated for indictment.[18]
This resistance to considering genital surgery as a form of mutilation is evidenced by refusals of medical journals to publish articles which oppose the surgical mutilation of intersexed infants; by proposed congressional bills which seek to ban FGM while explicitly permitting genital surgeries which are 'medically necessary'; by a refusal of health journals to publish papers on the negative effects of surgery for intersexuals; and by a refusal of women's studies journals to recognize the relevance of cultural misogyny to the abusive management of intersexuality.
Colorado member of Congress Patricia Schroeder is working on passing a bill that would ban FGM in the U.S. but the bill (HR 3270) explicitly permits surgical reconstruction for intersexuals. The New England Journal of Medicine has refused two critical articles on surgical reconstruction, one co-authored by By Laurent and Dr. Anne Fausto-Sterling and one by Melissa Hendricks. An article of mine on the subject was refused by the Canadian Woman Studies Journal on the grounds that there was not enough room in the special issue on Women's Health, however that issue published two 'traditional' views of African practices of FGM. A letter to the Intersex Society of North America (ISNA) from Fran Hosken, author of the often cited Hosken Report and politically active opponent of FGM, states that her interest in ending FGM does not extend to "biological exceptions" [October 25, 1993].
Is it fair to 'privilege' the removal of the genital tissue of people who are clearly female as mutilation while still maintaining--as Patricia Schroeder, Fran Hosken and the whole of medical science do--that the removal of the genital tissue of the intersexed is medically necessary? I say 'privilege' because the former group is receiving at least some recognition that what has happened to them is wrong while the latter group are reinstated as freaks, an arguably violent act, whenever it is said "But your case is different, you were a biological exception, we had to change you..."[19]
With the intersexed child it is easy to look at his-her body as a 'sick' one -- one that is diseased and in need of 'repair' or 'curative' measures. However, what I am positing in this paper is that the treatment to which intersexed children are subjected is indeed a form of violence that cannot be justified by calling these bodies 'diseased'. Indeed, or rather, it is the culture/society around the child which is dis-eased by the child's intersex characteristics.
Is it ethical to permanently damage the sexual organs of some people just so that those who (don't?) care for them can be made more comfortable? Who decided that it would be morally acceptable to erase the 'dismay' of parents, aunties and babysitters who might otherwise exclaim "My God!"[20] at changing time by removing the sexually sensitive, erectile tissue of infants and children? Is it acceptable to ensure the stability of the sexual binary and of heterosexuality by mutilating those who threaten the borders and limits?
Fausto-Sterling proposes a different way of doing things and I would like to close the paper with her utopian vision of the future as it might be. Here I ask the reader to consider the possibility that perhaps not only intersexuals, but all persons would do better in such a utopia.
True hermaphrodites could be called "herms", female pseudo hermaphrodites "ferms" and males pseudo hermaphrodites "merms". At birth, instead of hearing the inevitable pronouncement of "boy" or "girl" new parents might excitedly await a much expanded range of possibilities. Herms, ferms, and merms, being the rarer birth events might come to be seen as especially blessed or lucky, having as they do the best of all possible worlds, sexually speaking. Herms, merms and ferms might become the most desirable of all possible mates able as they are to pleasure their partners in a variety of ways. Furthermore, the existence of three additional sexes would open up possibilities for the rest of us. It would become difficult to maintain a clear conceptualization of homosexuality, for example, and perhaps its current contentious status would fade from view. If we envision the world in fives instead of twos, it would also be more difficult to hold onto rigid constructions of male and female sex roles. ...Should we have only two sexes?--my answer would be a resounding no [forthcoming, 104- 105].
Gonad:
organ which produces gametes (ova or spermatozoa). In the
early stages of fetal development, all gonads are
undifferentiated, that is: having the potential to develop into
either ovaries or testicles, or possibly, a combination of the
two.
Hypertrophy:
Literally: excess meat.
Intersex:
The combination, in a single individual, of
characteristics of both recognized sexes (male and female).
Sometimes referred to as hermaphroditism.
Male pseudo-hermaphrodite:
Individual with 'XY' sex chromosomes
and ambiguous or feminine genitalia.
Female pseudo-hermaphrodite:
Individual with 'XX' sex chromosome
and ambiguous or masculine genitalia.
True hermaphrodite:
Individual with both testicular and ovarian
tissue. The tissue may be combined in an 'ovotestis' or the
gonads may be separate. True hermaphrodites are, most
frequently, genetic females with an 'XX' karyotype. It is
possible that male genetic information ('Y' chromosome) is
attached to the 'XX' chromosomes in amounts sufficient to produce
both ovarian and testicular tissue in a single body. However,
contrary to speculation which borders on the mythic, it is highly
unlikely that such an individual could fertilize him/herself;
there is usually no sperm production in the testis although the
ovarian tissue may produce ova.
phalloclit:
I have created this term to describe tissue which is
not exactly a penis but also not a 'proper' clitoris. As a penis
it will be considered too small, as a clitoris, too large.
Doctor's usually refer to such an organ as a phallus until it has
been pared down to be an acceptable clitoris. Even when present
on an 'XY' individual with no endocrine, gonadal or karyotype
disorders, doctors will not call it a penis for fear that the
parents will resist its reconstruction (amputation) as a clitoris
which is its likely destiny.