Sex Binarism and the Intersex Pediatric Surgery Crisis

Posted on by BUJPH
Graphic of a surgeon and a baby

Illustration by May Qi

Article by Aisha Tipnis

 

Intersex variations are widely medicalized and often surgically altered to fit “male” or “female” phenotypes. These surgeries can have serious complications physically and psychologically, and because infants cannot provide informed consent, pediatric genital surgery is particularly problematic. Despite intersex activism and scientific literature indicating that these surgeries are harmful, they still occur. This paper explores why this problematic surgery continues to be performed due to the epistemologically Western, colonial, and biomedical perceptions of sex as binary form doctors’ foundational assumptions that intersex people should exist as one of two sexes, not the way they are naturally born. In doing so, this paper aims to elucidate pathways for change within a bioethical crisis.

 

A Background on Intersex Surgery

“Intersex” is a term used to describe anatomical, genetic, or hormonal variations in which an individual does not fit traditional definitions of neither “male” nor “female”.1 These sexes each describe an assemblage of traits that supposedly inhabit opposing ends of a spectrum. But sexual dimorphism in humans is not absolute: primary and secondary sexual characteristics appear in a range of concentrations and combinations. When this range exceeds boundaries drawn by scientific consensus, it is described as intersex. Seminal research conducted in 2000 by Dr. Anne Fausto-Sterling quantified this diversity, finding that 1.8% of the American population hold intersex variations.1 Intersex variations occur both frequently and naturally, rarely accompanied by health risks that require medical or surgical intervention.

Congenital adrenal hyperplasia, for instance, is a variation that produces relatively high levels of testosterone in XX carriers1. This genetic variation may manifest visibly with phenotypic traits like a larger clitoris and fused labia, which resemble a scrotum1. However, individuals with this genetic variation may simply display nonspecific traits like irregular menstruation, thicker body hair, or infertility1. Many individuals with congenital adrenal hyperplasia are unaware they hold an intersex variation at all. The phenotypic diversity within one single intersex variation makes it evident that sex is far more complex than the simplistic and somewhat arbitrary categories of “male” and “female.”

However, the medical community widely medicalizes and pathologizes intersex bodies. Despite the fact that infants cannot give informed consent, physicians routinely perform procedures like genital surgeries that the United Nations has condemned as “acts of intimate violence. Physicians routinely perform genital surgery on infants who cannot give informed consent.

Complications arise from these surgeries: scarring, incontinence, chronic pain, infections, sexual dysfunction, vaginal stenosis and fibrosis, neoplasia, and infertility3. Many surgeries further require a patient to undergo lifelong hormone therapy, future medical interventions, or daily manual upkeep of their constructed genitalia4. The risk of young children undergoing invasive procedures that implicitly medicalize and pathologize patients is that it enforces a self-concept that they are “not normal.” Subsequent shame leads to increased rates of depression, suicidal ideation, and gender dysphoria, which may result from an infant growing up to identify with a gender not socially associated with their anatomy4. To determine why these pediatric surgeries persist despite their potential long-term harm, and to question what is required for them to stop, this paper identifies the foundational assumptions they are predicated upon.

Following the formation of pediatric urology in the 1940s, Johns Hopkins University psychologist John Money developed some of the first procedures for intersex genital surgery. Money claimed that gender identity could be manipulated for the first eighteen months of life and argued that parents should raise their child as whichever gender was surgically easiest to “match” with their phenotypic sex — what Money thought to be “nature’s intention”5. Along with other physicians at Johns Hopkins, he set a precedent for making decisions without the child’s knowledge, without even the informed consent of parents, and with little research into patient outcomes6.

Contemporary physicians still follow Money’s precedent, altering intersex variations surgically to fit a more “male” or “female” phenotype7. Certain intersex variations may result in the presence of malignant tissue or the absence of a urinary opening, both bodily conditions which do necessitate surgery. However, most intersex genital surgeries performed on infants are deemed “medically necessary” not because of legitimate health concerns, but due to a supposed psychosocial benefit. Bewildered parents often defer to the authority of surgeons who, generally acting in good faith, hope their interventions will allow patients to “fit in” among strict social norms.

 

Western Biomedical Thought

Prior to the Late Middle Ages, Western epistemology was largely pluralist, valuing qualitative data and subjective thought8. It was the emergence of discrete measurements which catalyzed a push towards the quantitative, in which the most lauded thinkers saw the world in binary terms. Scholars newly presumed that any given thing could not both be itself and something else at the same time8. Uncoincidentally, at this time, a protocol became enforced in Europe that required intersex individuals to “choose” a singular gender role and maintain this role or otherwise face the penalty of death9. Social roles with logic heralded as rational, objective, and scientific followed suit, and the human condition was designated with dichotomous relationships — right or wrong, true or false, healthy or sick.

These relationships provided a foundation for Western scientific inquiry, which categorized the natural world with discrete boundaries in the pursuit of truth. These boundaries became increasingly clear as biomedicine developed through the 19th and 20th centuries, granting physicians with rarified technical knowledge that was considered “unbiased”10. But scientific consensus is not impartially correct so much as it is created and formed in a specific cultural context. In the “pursuit of truth,” there exists a pursuer, an actor imbuing their observations with preconceived understandings of the world around them. As Charles Rosenberg describes in Framing Disease, “…disease does not exist until we have agreed that it does, by perceiving, naming, responding to it…every aspect of an individual’s identity is constructed. So, also, is disease”10. Scientists do not exist outside of cultural norms; they use the faculties at their disposal in a specific socio-temporal context to form explanations for natural phenomena11. These explanations then serve to shape — and often reinforce — the same context within which they function.

Modern social movements disrupt the scientific consensus that has remained unquestioned for so long, examining the authoritative power medical experts claim over the lived experiences of individuals12. The sex binary, foundational to Western biological sciences, is one such fixture up for debate. Veronica Sanz describes this binary as an epistemological framework itself, a “common sense” so interwoven and entrenched in Western culture that it was never first questioned as a hypothesis13. It has always been a given, one which is now called into question as communities begin to uplift the voices of the marginalized, moving towards a scientific authority of embodied experience.

 

The Colonial Creation of the “Sex Binary”

The biological sex binary was firmly rooted into the American imagination as fields like embryology, biochemistry, psychology, and endocrinology developed. These 19th century advancements enabled Western physicians to assert that sex variation was diametrically opposed with newfound authority14. Along with other tools of categorization claimed to be biologically grounded, most notably race, sex provided a foundation to maintain Western hegemony8.

Before colonial rule, many civilizations held expansive understandings of sex and gender. The Zapotec people of Oaxaca defied standards set by 18th century Spanish colonizers through the existence of los muxes, community members assigned male at birth with traditionally-feminine social roles and gender performances15. Though they are often described as Mexico’s “third gender,” los muxes exist outside of the gender binary, similar to hijras in India. Hijras, born male or intersex, had been revered in India before 19th century British occupation16. Indian spiritual practices emphasize plurality and, before stigma against gender-nonconformity was generated by colonial rule, valued the coalescence of masculine and feminine energy16. Yoruba people in West Africa organized their communities in gender’s absence entirely, with the construct holding no comparable concept in their culture17. It was Europeans who introduced both race-based and patriarchal violence to the Yoruba people, compounding the subjugation of newly-defined “women”18.

 

Binary epistemology enabled Western colonizers to oppress populations and suppress pluralist, non-binary thinking that existed globally before — and in resistance to —colonization8. By claiming that white males and females were more visually distinct than sexes of other races, white people concluded that they were “more evolved” and thus justified in violently imposing their methods of social, spiritual, economic, and political relations upon “less evolved” groups14. Their presumptions were convenient: if one had to first be identifiable as a man or a woman to be a human, colonizers could strip those whom they colonized of their humanity by denying them access to the very gender system which they imposed19. Kevin Henderson explains that sex never was diametrically opposed, but instead was always “categorized along racialized degrees of difference,” retroactively engineered to justify Western hegemonic dehumanization and oppression20. Manhood and womanhood, therefore, are political categories weaponized against populations globally19. Gender and sex binarism are not innate to the human condition; they are constructed by Western imperialists.

 

“Biological Sex”: Fact or Fiction?

 Scientific consensus deems sex a biological category without a clear definition for classification. The countless ones offered — anatomical, hormonal, gonadal, chromosomal, genetic, neurological — only materialized in concurrence with advancements in specific fields of biomedicine. With the prior assumption that gender is biological, researchers proved their premise of a sexual binary classification using circular logic.

Wartime gynecological and urological exams in the late 18th century illuminated the variance of humans’ external genitalia6. Sexual classification was dictated by this visible anatomy until the development of gynecology and surgery in the 19th century, when internal reproductive organs became observable6. Victorian doctors consequently formulated a metric to determine the sex an intersex person was “supposed to have” based on gonadal tissue, an arbitrary metric which persists in contemporary medical thought: if someone had ovaries, they were female, if someone had testes, they were male, and only in rare cases that someone had both ovarian and testicular tissue were they intersex6.

The turn of the century brought with it advancements in cytology, ushering in a new chromosomal theory to explain biological sex: females had XX chromosomes and males had XY chromosomes13. Yet under a strictly chromosomal definition, there would exist at least six sexes: XX, XY, X, XXY, XYY, XXXY21. Not only do chromosomal combinations fail to support theories of absolute sexual dimorphism, but chromosomes also are subject to epistatic gene interactions and mutations which can alter phenotypic sex traits such that one’s chromosomal sex may be unaligned with their anatomical or gonadal sex1. For example, the presence of an SRY gene shifts ovarian development to testicular development regardless of the chromosome it is found on, even for XX carriers1. The presence of a WNT4 gene or the DAX-1 gene actively suppresses testicular development and stimulates ovarian development, causing XY carriers to develop intersex anatomy1. An individual may even exhibit mosaicism, possessing different chromosomal combinations in different individual cells21. Chromosomal explanations for sexual dimorphism fail to account for the sheer amount of human genetic variation.

The 20th century discovery of hormones, bloodstream chemicals that produce bodily functions, gave rise to an endocrinological explanation for sex. Scientists happened to find the first messengers in testes and ovary specimens and thus associated these so-called “sex hormones” — estrogen and testosterone — with gonadal sex13. However, estrogen and testosterone encompass wide groups of related chemicals affecting growth and development, which include reproductive and sexual function12. Other hormones also affect these functions, elucidating that “sex hormones” cannot actually define “sex” 1.

There are an infinite amount of embryonic and biological reasons for sex diversity; humans are not a perfectly dimorphic species, and sex has no consistent, categorical definition5. Scientists used emerging biomedicine and technology to explain what they already held as true. The sex binary, then, is not rooted in biology but rather in societal preconceptions of gender and sex.

Conclusion

This paper argues that gender is not innate to the human body, instead artificially formulated by Western colonial biomedicine through promoting a sex binary. Surgeons perform pediatric intersex surgeries under the premise that nature intends every individual to be either male or female, enforcing this very binary by allowing and disallowing certain bodies to naturally exist7. Though emergent activism at the turn of the 21st century substantially shifted the medical treatment of intersex variation, little has changed in recent years, suggesting a more fundamental problem. To break the positive feedback loop and to produce demonstrable change, Western, colonial, biomedical paradigms themselves must shift.

 

References

  1. Ainsworth, Claire. “Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic.” The Scientific American. (2018).
  2. Blackless, Melanie, Anthony Charuvastra, Amanda Derryck, Anne Fausto-Sterling, Karl Lauzanne, and Ellen Lee. “How Sexually Dimorphic Are We? Review and Synthesis.” American Journal of Human Biology 12, no. 2 (2000): 151-66. https://doi.org/https://doi.org/10.1002/(SICI)1520-6300(200003/04)12:2<151::AID-AJHB1>3.0.CO;2-F
  3. Behrens, Kevin G. “A Principled Ethical Approach to Intersex Paediatric Surgeries.” BMC Medical Ethics 21, no. 1 (2020/10/29 2020): 108. https://doi.org/10.1186/s12910-020- 00550-x.
  4. Kehrer, Ino. “Cuts into Children’s Future: a Comparative Analysis between FGM, Male Circumcision and Intersex Genital Surgeries.” Peace Human Rights Governance, 3(3), (2019), 333-363. 10.14658/pupj-phrg-2019-3-3
  5. Fausto-Sterling, Anne. “The Five Sexes, Revisited.” Sciences (New York) 40, no. 4 (Jul-Aug 2000): 18-23. h ttps://doi.org/10.1002/j.2326-1951.2000.tb03504.x.
  6. “What’s the History Behind the Intersex Rights Movement?”. Intersex Society of North America. (2008).
  7. Davis, Georgiann, and Erin L. Murphy. “Intersex Bodies as States of Exception: An Empirical Explanation for Unnecessary Surgical Modification.” Feminist Formations 25, no. 2 (2013): 129-52. http://www.jstor.org/stable/43860689.
  8. Reiter, Bernd. “Fuzzy Epistemology: Decolonizing the Social Sciences.” Journal for the Theory of Social Behaviour 50, no. 1 (2020): 103-18. https://doi.org/https://doi.org/10.1111/jtsb.12229.
  9. Fausto-Sterling, Anne. “The Five Sexes.” The Sciences 33, no. 2 (1993): 20-24. https://doi.org/https://doi.org/10.1002/j.2326-1951.1993.tb03081.x.
  10. Rosenberg, Charles E. “Framing Disease.” Chap. Introduction: Rutgers Univ. Press, 1997.
  11. Starr, Paul. “The Social Transformation of American Medicine.” Chap. Introduction, 3-29: Basic Books, 1982.
  12. Fausto-Sterling, Anne. “Science Won’t Settle Trans Rights.” Boston Review. (February 4, 2020).
  13. Sanz, Veronica. “No Way out of the Binary: A Critical History of the Scientific Production of Sex.” Signs: Journal of Women in Culture and Society 43, no. 1 (2017): 1-27. h ttps://doi.org/10.1086/692517.
  14. Schuller, Kyla. The Biopolitics of Feeling: Race, Sex, and Science in the Nineteenth Century. Duke University Press, 2018.
  15. Bushell, Alice. “Los Muxes: Disrupting the Colonial Gender Binary.” Human Rights Pulse. (June 11, 2021).
  16. Rhude, Kristofer. “The Third Gender and Hijras.” Religion and Public Life. (2018). Sanz,
  17. Oyěwùmí, Oyèrónké. The Invention of Women: Making an African Sense of Western Gender Discourses. University of Minnesota Press, 1997.
  18. Lugones, Maria. “Heterosexualism and the Colonial/Modern Gender System.” Hypatia 22, no. 1 (2007): 186-219. https://doi.org/https://doi.org/10.1111/j.1527-2001.2007.tb01156.x.
  19. Thomas, Greg. The Sexual Demon of Colonial Power: Pan-African Embodiment and Erotic Schemes of Empire. Indiana University Press, 2007.
  20. Henderson, Kevin. “J.K. Rowling and the White Supremacist History of ‘Biological Sex.” The Abusable Past. (July 28, 2020)
  21. Mittwoch, U. “Sex Determination and Sex Reversal: Genotype, Phenotype, Dogma and Semantics. ” Hum Genet 89, no. 5 (Jul 1992): 467-79. https://doi.org/10.1007/bf002191
  22. Reis, Elizabeth. “Did Bioethics Matter? A History of Autonomy, Consent, and Intersex Genital Surgery.” Medical law review 27, no. 4 (2019): 658-74.https://doi.org/10.1093/medlaw/fwz007.
Aisha Tipnis May Qi