- From the Editors
- (Not) Another Clit Story
- Caught Between: An Essay on Intersexuality
- Doctors Containing Hermaphrodites: The Victorian Legacy
- Finding the Words
- Growing up in the Surgical Maelstrom
- Hermaphrodites with Attitude Take to the Streets
- In Amerika They Call Us Hermaphrodites
- In Process
- Interview with Dr. Arika Aiert
- Is Growing up in Silence Better Than Growing up Different?
- Letter to My Physicians
- Meanings of Gender Variability Constructs of Sex and Gender
- My Beautiful Clitoris
- News Release: American Academy of Pediatrics Position on Intersexuality
- Ode to a Life (Poem)
- Porno Docs
- Power, Orgasm, And the Psychohormonal Research Unit
- Showering "Sans Penis"
- Silence = Death
- Take Charge! A Guide to Home Catheterization
- The Murk Manual: How to Understand Medical Writing on Intersex
- Time for a Change
- What dream? (Poem)
Doctors Containing Hermaphrodites: The Victorian Legacy
Alice Dreger, Michigan State University
In the early 1880s, a French woman, identified in medical records only as Sophie V., went to a local surgical clinic seeking advice and help. At the age of 42, Sophie had now been married two months to her first husband, but for all their trying he could not “accomplish the conjugal act” with her; he just could not seem to penetrate her vagina. The attending physician, identified in the record as Professor Michaux, examined Sophie’s genitals and quickly discovered the “problem”: Sophie V. was a man, no matter what she had been led to believe all of her life. She had a “penis” five centimeters long, albeit lacking the urinary- tract opening in the usual place. Her “labia” contained at least one testicle. And, Michaux noted, of course her husband couldn’t get his penis into her vagina, because she didn’t really have one!
Sophie understandably thought Michaux was either cruel or crazy. True, there had been some question about Sophie’s sex when she was born, and her parents had taken her to a medical man when she was but a few weeks old. As the medical journals records, at that time “the man of the art did not find the thing sufficiently clear, and he asked the parents to return later with the child.” Sophie’s parents did not, though, because they feared the man might operate on their child and accidentally hurt or even kill her. Instead they just decided Sophie must be a girl, and so she was raised. When she was in her early 20s, Sophie developed what she thought was a hernia, and she wore bandages to support it from that time forward. This “hernia” was, according to Michaux, the descended testicle. Now she was married to a man, one who wanted to penetrate her in a particular way but couldn’t seem to do so because Sophie lacked the parts. What to do?
The answer to the medical man Michaux was simple: Sophie had testicles and a penis; she was a man; she was therefore not really married (no matter what she thought) because no marriage between two men was a true or legal marriage. She—or rather he—should have his civil status formally changed to male and start acting his “true” sex. Sophie was a man.
The answer to Sophie was equally simple: She felt like a woman, she dressed like a woman, she had always been a woman. She was married to a man whom she loved and who loved her. The doctor was either crazy, or wrong, or confused, or at least not worth listening to. Sophie had no interest in becoming a man. Sophie was a woman.
Sophie V. had the sort of anatomy that in her day qualified her to be labeled in the medical literature a “hermaphrodite.” This is still a common use of the term in our vernacular, although medical experts have grown much more specific with regard to distinguishing one kind of “ambiguous” genitalia or “intersex” from another (more on that later). Sophie’s genitals did not look much like your supposedly- standard male or female type, but more like something in between, or something fairly different, and this was what, in the nineteenth century, generally made one a “hermaphrodite.” In Sophie’s time, the word “hermaphrodite” was sometimes also used to refer to people who today would likely be classified as transvestites, transsexuals, homosexuals, feminists, bearded women, and so on. But when identities got sorted out in the way they did in the nineteenth century, “hermaphrodite” came to refer fairly specifically to people born with unusual genitalia.
Most people labeled male have one penis each, a scrotum, two descended testicles, a prostate, no vagina, penile erections and ejaculations, and so on. Most labeled female have one clitoris each, a vagina, two ovaries in the abdomen, no testicles, erections (in this case of the clitoris), a period of life in which they menstruate, and so on. But human anatomy is amazingly variable, intentionally and unintentionally. A fair number of babies are born with internal and/or external organs that don’t fit the “most” description of malehood or femalehood. How many is hard to say. Such statistics depend on definition (what is a standard penis? or an acceptable vagina? what should be counted as intersexual, or ambiguous?), on examination techniques and standards, on record-keeping and reporting of statistics, on frequency of variations within a given sample, and so on. But I think we can say with confidence that at least one in every two or three thousand births results in a question about the sex of the child. Add that up and it comes to thousands of cases per year in the US alone.
So unusual sexual anatomy is not really all that unusual, not nearly as unusual as most people assume. Until graduate school, I had never known about it, and I meet people all the time who have never heard of it until they met me and asked me what I research. Even people who were born “intersexed” may not know of the phenomenon, since they are often never told the diagnoses written in their medical records. But people in the medical profession know it isn’t too rare. Doctors are trained to be on the lookout for intersexuality, and it is standard material in all medical genetics, gynecology, and urology textbooks. Medical students in the course of their education all learn about “intersexuality,” and most gynecologists I talk to eagerly tell me about a number of cases they’ve personally seen. Today almost every major hospital has a standard protocol for what to do when a child is born whose sex is confusing or suspicious.
Intersexuality is even becoming more visible in pop culture. The recent movie “Flirting with Disaster” featured a bisexual (interesting choice) who was born with a hypospadic penis, that is, an organ like Sophie’s that looks like a penis but doesn’t have the pee-hole in the usual place; a recent episode of the television drama “Chicago Hope” included a story of a baby born genetically male but with an unacceptably small penis. (The doctors in that story decided, as is generally the case in the US today, a boy with a wee penis is no boy and so the child should be made— hormonally, surgically, and socially—a girl.) As possibilities for sex/gender identities expand and become inhabited by more and more people, interest in intersexuality grows.
I am a social historian of science and medicine, and I became interested in the scientific and medical treatment of hermaphrodites because so much literature has been written lately on the social construction of gender, but I wanted to know how “sex” (“male” and “female” anatomy and physiology) came to be thought of the way it is today. After all, although we often act as if it is, “sex” is not a completely self-evident thing. We say a hermaphrodite is a person with unusual sexual anatomy, but when you come right down to it, what is sexual anatomy? What do you count, and how do you count it? Do you have to have a penis to be a male? If so, what size, and when do you have to have it—at birth? At the moment in question? Do you have to—or have to be able to or have been able to—become pregnant to be a female? Or is it just those XX and XY chromosomes? If so, are women with XY chromosomal bases not women, even though they are born with female-looking genitalia and develop like most females at puberty? (This is the case in people with an XY-chromosomal basis and a condition now described as androgen-insensitivity syndrome, or AIS.) Is it the case that those of us who don’t know if we are XX or XY don’t know our sex?
As the Olympic Committee— which keeps trying to figure out who should count as a male athlete and who a female—has discovered the hard way, none of these possible sex signifiers alone really suffices to capture the usual way we think about sex, even if we claim they are the ultimate, true, sexual signifiers, because there will always be people we are willing to count as male or female who don’t fit any given definition. Do we then use a sort of “Cosmo girl” test and say that, if you have, say, “five of the following” traits, you count? Perhaps such an additive system would work. But then one would still have to decide what to add. What size would a phallus have to be to count as a clitoris or a penis? Would one have to wait until puberty to see what happens with the breasts, the body hair distribution, and so on? More to the point, what would count as sexual anatomy in such an additive system? If in Sophie’s time, as was the case, most women had long hair, should head hair have counted as part of the sexual anatomy? (English doctors said it should, and French doctors it shouldn’t.) And if, as Darwin claimed, the females of most human races were fairer-skinned than the males of their races, should skin color count towards sexual anatomy? But, wait, we wouldn’t count those anymore. Well, then, is the question of what counts as “sexual” specific to time, place, culture? That, too, seems strange—most people want to say some parts always counted and always will count for malehood and femalehood, that there is a single “real” maleness and femaleness, even if we can’t fit everyone into that definition.
What I find is that it is those tense and tentative definitions of “real sex” which reveal so much about how we think about and limit sex, and, much more frighteningly, it is those definitions to which people like Sophie, the fictional baby on Chicago Hope, and real children born today are subjected. When I started this research, I assumed it would tell us good things for people who believe in the goals of radical feminism and the queer rights movements. It has. It has told us that, like gender, sex and sexuality are concepts which are in very important ways historically developed and culture-specific. But it also tells us some frightening things about what happens to intersexuality and people born intersexed. This history matters more than I ever thought it would, in some ways more than I wish it would, for I wish things looked pretty good compared to the way things used to be, and I don’t find that to be the case.
For the last several years, I have been working on a large study of the biomedical treatment of human hermaphroditism in the late-nineteenth and early-twentieth centuries. I am currently writing a book on the subject, and in the space here can only touch on some of the larger points. What makes the period I study so interesting is that it was a time when much was in flux. Scientists and medical doctors did not yet hold the sort of phenomenal cultural authority they would come to hold in the mid-twentieth century. Theories of sex, embryology, evolution, and so on were in periods of intense debate and development. And finally, this was a time when dominant sex roles were being increasingly challenged, with vigor as never before, especially by feminists and homosexuals. What a time to be a medical man faced with a person like Sophie! Increasingly it was specifically the medical man who would be faced with such people, for in the nineteenth century as never before, the sexual anatomy of the masses—like all other aspects of human sexuality—became the purview of the medical profession.
What I find in my research is basically this: Increasingly as the nineteenth- century and then the twentiethcentury progressed, medical and scientific men did all they could, conceptually and practically, to limit each and every body to a single sex. In the nineteenth- century it wasn’t enough to just pick; the sex assigned had to be what they called the “true sex” of the body. Every body was assumed likely to have a single true sex, male or female, a true sex that could be masked by ambiguous anatomy or “strange” behavior, but unmasked by the able medical man.
And, as experts reminded their sometimes-provincial colleagues, it was up to the medical man to make sure everyone was sorted and sorted right. Otherwise one might end up with “perverse” cases like Sophie’s, where men unknowingly engaged in sexual relations with other men, or cases like Herculine Barbin’s, in which a masked man “accidentally” penetrated the sanctuaries of women and… well, penetrated the sanctuaries of women.
The clinical problem was how to figure out what each person’s true sex was. The combinations could be quite confusing—breasts on men, beards on women, genitals that seemed to be a little of both or a lot of neither. Medical men fretted over cases in which so many traits seemed to contradict the “sex” of other traits, traits including voice pitch, genitalia, hair distribution, fingernail quality, breast development, angle of the knees, quality of the gaze, sorts of desires. In fact, even though they never doubted that there were two, and only two, distinct human sexes, medical men of the nineteenth century had a devil of a time agreeing what sex was, or more specifically, on what should count as the necessary or sufficient signs of sex. Yet they were, as a group, increasingly reluctant to allow that any body could be a true hermaphrodite—a person truly both male and female—and doctors grew increasingly interested in keeping every body sorted lest sexual havoc ensue. It was bad enough that people like Oscar Wilde and Susan B. Anthony questioned social borders; the last thing the social body needed was doubts about the anatomical borders on which the social borders had been constructed!
The logical solution was the one chosen by biomedical experts: pick a single binary trait which could be used to sort otherwise ambiguous bodies. In the 1890s, a consensus emerged, according to which “true sex” would be signified by the gonadal tissue, that is, ovarian or testicular tissue. Does Sophie look confusing? Well, the rule went, if she has testicles, she is simply a man; if ovaries, a woman. This seemed like a good solution.
Why the gonads? After all, why not pick something more readily accessible, like breasts, or facial hair? The gonads made a good signifier in part because they were binary and doctors wanted to envision sex as binary. Gonadal tissue postnatally tends to be pretty easily identified as ovarian or testicular in nature. (An awful lot of men have breasts and a sizable number of women have mustaches.) Besides, it seemed like the gonads were the key to sexual identity; after all, what is a man but a person who can impregnate via his sperm, and what is a woman but a person who can produce ova and thus be impregnated? Even if not all men and women were fertile or active in these ways, it seemed like a logical defi- nition, especially at a time when men and women were almost universally in scientific and popular texts described as mere manifestations of their reproductive roles. Late-nineteenth century biomedicine was also very focused on tissues as key (especially in research on disease), so it seemed logical to assume that the tissues held the answers in this case. Finally, there were growing hints that gonads produced some sort of “internal secretions” (what would later come to be known as hormones) which in turn played important roles in sexual development.
Still, with all these good reasons to pick the gonads as signifiers, the chief impetus to pick a single signifier was the practical messiness of sex—the blending of and disagreements over the plethora of “sex” traits. Almost every body had either ovarian or testicular tissue, and almost none had both or neither. This meant almost everyone could have a single true sex. Additionally, while it was agreed by most doctors then and now that some people really do have both ovarian and testicular tissue, in the 1890s, clinical techniques did not allow for the required microscopic diagnosis of living true hermaphrodites, so the threat of true hermaphroditism was satisfactorily subdued. At least everyone living would seem only to have one true sex which they could be advised to heed.
This, then, was the gonadal defi- nition of true sex, the definition that has stuck in the technical literature all the way up until today. As was developed in the nineteenth century, the medical classification system for intersexuality now divides us all up into five basic types: males have testicular tissue and are “unambiguous”; females have ovarian tissue and are “unambiguous”; “ambiguous” people with testicular tissue are called male pseudo-hermaphrodites; “ambiguous” people with ovarian tissue are called female pseudohermaphrodites; and those rare people with ovarian and testicular tissue are called true hermaphrodites. These are what Anne Fausto-Sterling helpfully abbreviates as males, females, merms, ferms, and herms. She also suggests we accept and broadcast this five-sex system of classification.
So, are all people like Sophie now assigned a sex identity according to their gonadal tissue? Well, no. After all, what the heck is one supposed to do with a true hermaphrodite, or a woman with testicles, if you want to assign everybody according to gonads and still maintain the “old-fashioned” ideas of sex? This very real problem emerged in the early twentieth century because of the development of new diagnostic techniques, namely laparotomies (exploratory surgery) and biopsies (sampling of tissue without removing the whole organ). Now a doctor could diagnose a living true hermaphrodite, but the legal and social system wasn’t ready to handle it.
And, even if you could figure out a way to cope with true hermaphrodites —and those were pretty rare and so not too threatening to the system—it was becoming clear that a relatively frequent condition existed in which a patient could look, sound, act, and feel for all the world like a female but would have testes! This is the condition now known as androgen insensitivity syndrome (AIS) or testicular-feminization syndrome. We understand this as a case in which a genetically-male individual has testes which produce testosterone but her/his body can’t “read” that testosterone (the receptors are lacking). AIS individuals are often classic Western womanly beauties with a female vulva, long limbs, hairless bodies and faces, rounded hips and breasts, “feminine” voices. (There is a rumor that many women high-fashion models are actually AIS “males,” a claim which, whether or not true, I enjoy suggesting to my undergraduates who belong to the more sexist and heterosexist fraternities and sororities.) While the explanation for AIS remained elusive in the early twentieth century, the phenomenon was well documented, and diagnostic techniques now allowed easy identification of such cases. Were these people to be assigned male because they had testes? What would stop other “women” from claiming they were really men and demanding such “male” rights as the vote? The gonadal definition seemed now, in practice, completely unacceptable, even if in theory it allowed easy sorting.
And so there began in medical practice a retreat to the external genitalia. We often think of the emergence of the concept of gender identity as a twentieth-century step toward liberation, away from traditional sex roles, and indeed it was in the realms of gay rights and feminism. Freeing “gender” from “sex” meant freeing oneself from claims that traditional sex roles emerged from an indelible biological reality. But in medical treatments of intersexuality, ironically, the concept of gender identity (an identity beyond anatomical sex) emerged specifically so that traditional social concepts of sex and sex roles could remain undisturbed by messy bodies. In theory doctors retained the gonadal definition of sex with five categories (male, female, merm, ferm, and herm), but in practice such a definition would have required a new social category of a third sex (for true hermaphrodites) as well as the labeling of very womanly AIS patients as men. This would have meant some rather profound social disarray or at least some important changes. So in practice doctors increasingly decided to assign a gender identity to each patient—strictly boy/man or girl/woman—according to what a person’s social role already was or was likely to be given that person’s appearance. The earliest suggestion I have found that doctors make practical “gender” assignments was in 1916. In the text the author, an English surgeon, suggested that such a clinical solution would ensure that pretty girls could still get married even if their sex was technically confused or confusing. The desire for social stability, combined with the exigencies of new diagnostic technologies, drove medical men in this direction.
So today, theoretically at least, women have the same rights as men, and being gay or lesbian is supposed to be acceptable to medical professionals. One might expect to find a greater tolerance, then, of ambiguous sex, since we tolerate more “ambiguous” gender roles. Alas, such is not the case. Today, as Suzanne Kessler has documented in her 1990 article in Signs, ambiguous babies are typically sorted early into girls and boys in this way: Genetic and gonadal males with small or otherwiseunacceptable (and unbuildable) penises are made into girls, for a “satisfactory” penis is considered the sine-qua-non of boyhood. Babies born with workable female reproductive systems are made into more-convincing girls, even if that means destruction of the clitoro-penis and other parts. Doctors seem to think very little of deciding a child will be put on hormone therapy for the rest of his/her life.
“Normal” has two basic meanings. In one sense “normal” is used to describe the average or typical. But in another it is used to speak to an ideal, a perfect sample. The word was first used mathematically to describe a kind of angle, namely a right angle (ninety-degrees), and we see even in that term—right— those two meanings, one descriptive (as in ninety-degrees) and one prescriptive (as in correct). So too we have the “most” definition of sex as given above most people labeled female have labia minora and majora, a clitoris, etc. and that is a definition of normal sex in the first sense, that is, in the sense of typical sex. But, as in so many areas of cosmetic surgery, the definition slips from the descriptive norm (what is average) to the prescriptive (what is ideal, what must be), and massive amounts of medical treatment are brought to bear to attempt to make acceptable-looking girls and boys out of “unacceptable” children. This was already starting to happen in the late nineteenth century. For instance, surgeons, particularly in France, worked to develop techniques to remake hypospadic penises so that patients with the condition could pee standing up. In a case very similar to Sophie’s, a French surgeon offered to make his patient a more workable vagina. (The surgeon was soundly reprimanded by colleagues who accused him of contributing to a “perverse” situation, namely a marriage between two “men.”) There are two differences today: Today the surgeries attempted are far more ambitious, and they are typically performed on babies or children. The logic is that any child left to grow with ambiguous genitalia will suffer irreparable psychological harm. This sort of extraordinary surgery is known in medicine and history of medicine as “heroic” surgery; this refers to attempts to perform—against the odds—the seemingly impossible. When the surgery doesn’t work—when it results in scar tissue, dysfunction, disfigurement—that in a way seems OK, because it was, to start with “heroic” in its aim.
But is this heroic? Doctors tell themselves and us that they do these sex-assignments and sex-therapies for the sake of the individual patients, and they must believe this in order to do what they do. But if we look at the effects, we must wonder. Is there good evidence that, from a medical point of view, the time to treat cases of genital ambiguity is pre-puberty? Or does this often result in sexual and urinary dysfunction and disfigurement? Is it true that no one could psychologically survive a big clitoris, a bifid scrotum, a hypospadic penis? Are the genitals shaped by the scalpel necessarily less traumatic than those shaped in the womb?
Given the apparent lack of followup studies to show whether these surgeries work most of the time, physically and psychologically, and given the tragic stories of many medically reshaped hermaphrodites, one must wonder if this is “heroic” or just misguided, even heady. Any reasonable person who takes a close look at the literature cannot but conclude that the current treatment of intersexuality has far more to do with social needs regarding sex borders than the child’s or even the family’s needs. If the patient and family were the chief concern, adequate follow-up studies would be done, peer-support groups established and made known, and regular psychological counseling offered. I strongly suspect, also, that the ethos of surgery forces this sort of treatment— an ethos which dictates the surgeon must always recommend surgery and must always attempt the difficult or impossible, indeed the most “cutting edge” pun painfully intended solution. (There is a saying in medicine about the three basic rules: If it works, keep doing it. If it doesn’t work, stop doing it. And never go to a surgeon unless you want surgery.)
If I look back in history, to times we tend to consider less liberal, less accepting of difference, I find that in fact hundreds of hermaphrodites like Sophie survived. Yes, some were traumatized, some ostracized, some confused. But we see also people who just went on, who didn’t much care, who found lovers and friends and lives as they were. There is, for instance, the tale of the French peasant vineyard-worker and his bearded wife, a wife whose beard did not bother her husband; the story goes that they each shaved once a week for mass, and no one really questioned her beard since vineyard-workers were known to be particularly strong and virile. How varied are the stories! It pains me to no end to see, repeatedly, the story of Herculine Barbin, a nineteenth-century French hermaphrodite, used to make the claim that all hermaphrodites left alone would kill themselves as Barbin did. Barbin was in fact not left alone—her sex was reassigned to male, perhaps as she wanted and perhaps not. No better is it for us to claim she killed herself because of the reassignment. Why Barbin did commit suicide will never be known for sure. But we can see that, before the days of early diagnosis and early treatment, many hermaphrodites survived, had lovers— just lived.
So too were the approaches of the doctors remarkably varied before the time when medical training became standardized and hermaphroditism experts and protocols emerged to rule the day. How many definitions of sex there were, how many opinions of how to settle questions of sex. Perhaps this did not make things any easier on any individual patient, but it shows to us the faint signs, like faded cave paintings, of all the roads not taken, all the roads we could go back and try to take.
And so I find myself wondering if we can start to change the definition of heroic medicine, away from one which regards as heroism extraordinary attempts to shape the identity of a baby (or anyone else) according to the received limits of acceptable identities, and towards one which regards as heroism the willingness to question medical tradition, to question colleagues’ judgments. I dare to envision a new road taken, a road of honesty about intersexuality, a road along which we find the active encouragement of acceptance of anatomical diversity, a road towards a world of medicine in which the patient’s wishes are at least seriously considered, if not followed.
Historians—since we care about dates—have a habit of putting the birth dates and death dates of various important figures after the first introduction of their names. For example, ‘Jane Smith (1874-1920) was well known for her use of split infinitives.’ When I was working on my book, I instinctively stuck in the birth and death dates after the introduction of each of the important doctors who treated hermaphrodites. One day I realized I should do the same thing for the particularly famous hermaphrodites whom I was introducing—Herculine Barbin, Marie-Madeleine Lefort—and wham! Suddenly they came to life as people who had been born and who had died—they were historical figures. Until that time they must have occupied in my mind the same sort of position they did in most of the medical folklore—unusual characters who pop in and out with mythical, often tragicomic lives. Now they were real. They had achieved a parallel existence with the doctors. They had finally been awarded the great historical parenthetical tombstone they had earned.