Meanings of Gender Variability Constructs of Sex and Gender

Paper presented as part of a plenary symposium titled “Genitals, Identity, and Gender,” at the Society for the Scientific Study of Sexuality, November, 1995, San Francisco.

Suzanne J. Kessler, Purchase College, State University of New York

In our world there are two different kinds of genitals to mark the two genders. In spite of this apparently obvious fact, there is a natural range of genital formations within the two genders. There is variation in penile and clitoral sizes, labial lengths, vaginal depths, degree of scrotal fusion, and amount of testicle mass.

Medical standards permit infant penises as small as 2.5 centimeters to mark maleness and infant clitorises as large as 0.9 centimeters to mark femaleness. Infant genital appendages between 0.9 cm. and 2.5 cm. are unacceptable (Fig. 1).

chart of clitoral and penile lengths

Figure 1. Clitoral & Penile Non-Erect Lengths at Birth (cm)

Genitals that don’t meet size and shape standards are typically referred to by physicians as “ambiguous.” Some are ambiguous in the sense that they don’t clearly match either the male or female gender. Others are “ambiguous” because, even though they match one of the genders, they don’t do it very well. They aren’t good representatives of the genital category. For example, the penis is a micropenis or the clitoris is enlarged. The scrotum is not fused enough or the labia are too fused. Pediatric surgeons “fix” these genitals, so that we end up with diminished genital variability within the genders, and exaggerated differences between the genders. It’s not just infants and children who are subject to efforts to “correct” genitals that aren’t “good enough.” In a world where fashioning the perfect body is more and more of an obsession and technical solutions are more and more available, it’s not surprising that there are adults deciding to exercise their right to reshape or ornament their genitals. Men and women are piercing their genitals; some women are getting their labia trimmed; some men are getting their foreskins restored or their penises thickened.

Table 1. A Comparison of Terminology

Pre-Surgical GenitalsInterventionPost-Surgical Genitals

At the heart of this issue are assumptions about how seriously to take genitals and what genitals are essentially for. Are they essentially for signaling gender—in that sense a guide for physicians and parents? Are they essentially for ornamentation and pleasure—in that sense for oneself and one’s sex partners?

Let’s look at some of the terminology (see Table 1): On the first line is the conventional terminology of medical professionals. On the second line is an alternative terminology used by critics of the “status quo,” including members of the intersex advocacy movement and members of the anti-circumcision movement. For example, the latter describe circumcision as “amputation.” Instead of referring to foreskin removal as a “snipping” of the foreskin as physicians would, anti-circumcision activists write about “stripping of the glans” and even “skinning the infant penis alive.” They accuse the medical profession of being inconsistent by treating circumcision as natural since, when on rare occasion a male is born without a foreskin, it is noted in his records as a birth defect, suggesting that the foreskin should have been there all along. Intersexuals, who are politicking to change the way the medical profession thinks about intersexuality, argue that the term genital “ambiguity” is predicated on assumptions about the naturalness of two genders, and actually creates the intersex category. The term “variability” that I’ve used in the title of my talk is deliberately neutral.

Who has the power to name? Those who are happy with their own surgically altered genitals, or their children’s, or their patients’, never refer to circumcision or intersex surgery, or other genital surgeries as “genital mutilation.” In contrast, some of those who are subjected to such surgeries never refer to them as “medical advancement.”

I would like to explore some possible meanings of genital variability (Table 2). Meanings 1, 2, and 3 assume a link between genitals and gender and reflect the viewpoints of the medical establishment, which has strict criteria for genitals and technical solutions for variations. Meaning 4, although medical in its outlook, doesn’t link the meaning to gender. This could be the primary medical attitude, in a different world.

Table 2. Possible Meanings of Variable Genitals

  1. Your genitals signify neither of the two gender categories. We need to know what gender you are, therefore we must do further testing. (This meaning implies medical diagnosis, but not necessarily surgical intervention.)
  2. We know your gender. Your genitals signify the wrong gender. We must operate to make them conform to the right gender. (The “must” implies that surgery is a medical advancement.)
  3. We know your gender. Your genitals, although not within the normal range for your gender now, will be in the future. We expect they will clarify on their own. (For example, children with 5-alphareductase deficiency raised as males).
  4. Your genitals are providing a clue that there is an underlying medical problem that needs to be addressed. We prescribe a non-surgical treatment. (For example, medication for children with the salt-losing form of CAH.)

Meanings 1, 2, and 3 assume a link between genitals and gender and reflect the viewpoints of the medical establishment, which has strict criteria for genitals and technical solutions for variations. Meaning 4, although medical in its outlook, doesn’t link the meaning to gender. This could be the primary medical attitude, in a different world.

In addition to these four meanings, there are four others (Table 3). Meanings 5, 6, and 7 reflect a conceptualization of the genitals as either aesthetic objects or as just another body part. Meaning 5 is promoted by some plastic surgeons, while meaning 6 is promoted by some members of the transgender community. Meaning 7 might be something worth working toward. Meaning 8 is, I believe, at least part of the significance given by some parents to their childrens’ genitals. I won’t talk about that today.

Table 3. More Possible Meanings of Variable Genitals

  1. Your genitals are inferior (less functional, ugly). We pity you and suggest you have corrective/cosmetic surgery.
  2. Your genitals are superior (more versatile, attractive). We envy yours and want ones like them.
  3. Your genitals are just another body-part that varies from person to person, like noses and ears, and it doesn’t matter what they look like as long as they function well. We don’t think that much about your genitals or our own.
  4. Your genitals signify something about your parents. They have misbehaved or are genetically unsuitable. They are embarrassed by you and your genitals.

Meanings 5, 6, and 7 reflect a conceptualization of the genitals as either aesthetic objects or as just another body part. Meaning 5 is promoted by some plastic surgeons, while meaning 6 is promoted by some members of the transgender community. Meaning 7 might be something worth working toward. Meaning 8 is, I believe, is at least part of the significance given by some parents to their childrens’ genitals.

It is obvious which meanings have more authority now—the ones that reify gender. We need to think more about the advantages and disadvantages of acknowledging or promoting genital variability. I don’t have much time to talk about this today, but it is something I am working on.

I’m proposing here, at least as a working hypothesis, that it would be good to broaden the criteria for what constitutes normal looking genitals. Larger-than-typical clitorises and absent vaginas should be acceptable for girls and smaller-than typical penises and misshapen scrotum should be acceptable for boys. In other words, what we mean by a female or a male must be given more latitude in the body, just as people have been arguing for more latitude in behavior. How would such a genital re-conceptualization start, and how would it impact on ideas about gender?

It’s striking that in the medical literature, although ambiguous genitals in and of themselves rarely pose a threat to the child’s life, the post-delivery situation is treated as life-threatening and the genital surgery is described as necessary. Yet I’ve delineated three categories of distinguishable genital surgery:

  1. saves life
  2. improves quality of life
  3. satisfies social needs

1) Some genital surgery is life saving, e.g. a urethra needs to be re-routed so that the infant can pass urine out of the body; 2) Some surgery improves the quality of life—e.g. the urethral opening needs to be redesigned so that the child can eventually urinate without spraying urine on the toilet seat; and 3) Some surgery is social [e.g. the penis needs to be refashioned or enlarged so that the (eventual) man will feel more manly and be better able to satisfy his sexual partner].

The focus of my work is on the third category and how it is too often merged with the other two. Medical professionals discuss how important it is that genitals look “right” as a potential life or death issue, with the assumption that “wrong” or “bad” looking genitals can have serious, perhaps fatal psychological consequences. This is a largely untested hypothesis.

Despite this rhetoric, though, there is very little research on what people think about how their genitals look. I’ve collected some preliminary data on what college students think about their genitals and will be reporting today only on answers to one set of questions. The women were asked: “Suppose you had been born with a larger than normal clitoris and it would remain larger than normal as you grew to adulthood. Assuming that the physicians recommended surgically reducing your clitoris, under what circumstances would you have wanted your parents to give them permission to do it?” The men were asked to imagine being born with a smaller than normal penis and told that physicians recommended phallic reduction and a female gender assignment. All the subjects were shown a scale with the normal ranges for clitorises and penises demonstrated in actual size, and labeled in centimeters. It’s reasonable to question exactly what we can infer from these subjects’ answers, but I’ll first report the findings.

About a fourth of the women indicated they would not have wanted a clitoral reduction under any circumstance. About half would have wanted their clitoris reduced only if the larger than normal clitoris caused health problems. Size, for them, was not a factor. The remaining fourth of the sample could imagine wanting their clitoris reduced if it were larger than normal, but only if having the surgery would not have resulted in a reduction in pleasurable sensitivity. Only one woman mentioned that other people’s comments about the size of her clitoris might be a factor in her decision to have surgery. My analysis of medical follow-up studies suggests that clitoroplasty and vaginoplasty results are far from perfect. For example, scarring, insensitivity and discomfort are not uncommon. These results are confirmed by an independent meta-analysis by biologist Anne Fausto-Sterling and sexologist Bo Laurent. Given these findings, my sample’s hesitancy about genital surgery under most circumstances ought to make physicians think more about whose needs they are serving when they recommend genital surgery for infants and young children.

What about the men? All but one man indicated they would not have wanted surgery under any circumstance. The remaining man indicated that if his penis were 1 cm. or less and he were going to be sterile, he would have wanted his parents to give the doctors permission to operate and make him a female. Granted the males were given a different and more difficult choice to imagine than the females—either living as a male with a small penis or not being themselves at all, being a female. You could argue that because of this impossible choice, their wish to live with a small penis is uninformative. And yet, these men know what is required to be a male in our culture, and they seem to be saying that it is possible to be a male, regardless of the size of their organ.

There’s no reason to expect that college students’ suppositions about what they would have wanted as infants matches what prospective parents would want for their infants. I’m guessing that parents would be more conservative in their choice of genitals for their children. (And I should have data available soon on that point.) What would a difference in perspective between the hypothetical grown up infant and the hypothetical parent mean? I don’t believe that parents’ predictions about what’s in store for their children without surgery are any more likely to be accurate than college students’ predictions about what it would have been like to grow up with genitals that varied from the norm.

Given this inability to predict, should physicians continue to satisfy the parents’ need to have a presentable child? Or should physicians be more attuned to the potential needs of their patients? One argument physicians make to justify doing immediate surgery on intersex infants is that this will maximize the child’s social adjustment and acceptance by the families. Implicit in this defense is that the genitals themselves carry the burden of evoking acceptance. There’s no sense that the burden is (or ought to be) on the parents to learn to accept the genitals. One endocrinologist who specializes in treating intersexed infants said in an interview with a reporter that not doing the surgery would be unacceptable to parents because “some of the prejudices run very deep.” This assertion ignores the fact that many prejudices that physicians collaborate in maintaining have changed over the last few decades. For example, in the l990s psychiatrists are at least somewhat less likely to accede to a parent’s wish to “transform” a homosexual adolescent into a heterosexual one than they were in the 1950s.

Because physician-researchers (and not parents) publish articles, the parents’ perspective is missing from most discussions of intersex management. One mother who was dissatis- fied with the level of support provided by the medical profession wrote a letter to a woman’s magazine asking to hear from other parents who had a child with Congenital Adrenal Hyperplasia (CAH), a condition that sometimes involves non-typical genitals. Over the next year she received letters and phone calls from more than a hundred different people, mostly parents who had never talked to anyone outside their family about their child’s condition and who had never personally known of another family with a CAH child. She generously allowed me to read these letters, and they provide a glimpse of what the parents of intersex infants think about their “education” from the physicians and what they think about their intersexed children. I don’t have time here today to discuss all of what I learned from these letters, but instead will confine myself to a few issues related to the meaning of genital variability. It seems to me that some parents are taught by the doctors that what looks like a perfectly normal child to them, is not. They are taught to ignore their sense that the genitals are unremarkable and just another feature in the context of a beautiful baby. The physicians, as authorities, define the genitals as outside the normal range, and are often granted the authority to undertake any kind of alteration.

One parent wrote, “He was a perfect male, but his testes never dropped into the scrotum.” Another said, “She was born perfectly healthy and looking like a girl—but she had skin fusion, and no opening to her vagina, which her urologist wants to correct soon. Another mother wrote, “We thought we had two perfectly healthy children. The bomb fell when I took [my daughter] to her two week check up. Her pediatrician discovered that she had no vaginal opening. He very gently told me that she had what was called “ambiguous genitalia.” Although the parents needed to be educated about their child’s medical abnormality, from a “looks” point of view, what they saw looked normal to them. Each example suggests that some parents do not have as strict criteria for what constitutes normal genitals as the physicians who have diagnosed an underlying disorder. In another family the presumably normal baby girl was taken home after the birth only to be returned to the hospital six weeks later with breathing difficulties. The mother wrote, “They told us she may possibly be a boy. Her clitoris was enlarged but her vagina had only closed partially. However the lips that overlap the vagina had not formed. Tests proved she was definitely a girl and a very slight operation around one year old opened her vagina to the proper length. That was all the surgery she needed. The large clitoris now seems smaller as her new body has grown around it.” There are two important points about this last example. First, this girl with an enlarged clitoris and unusual labia was unremarkable to these parents, and presumably to the physicians who delivered her, until it was discovered a month and half later that she had CAH. Second, clitoral surgery was averted by just waiting long enough for the body to grow, a management strategy that is not followed often enough. How many surgeries might be avoided if physicians would just wait and let nature take its course—“nature” being either the body changing on its own and/or the parents coming to accept the genitals as a reasonable marker of the child’s gender?

The physicians, and subsequently the parents, place disproportionate emphasis on how the post-surgical genitals look, as opposed to how well they function. A number of the letters contained general assertions about the “success” of the surgeries in terms of how the genitals look. For example, after a second clitoroplasty a six-year-old girl’s mother wrote, “It looks better than it did, but my husband thought maybe another operation, but I think it’s fine like it looks now! Her vagina looked good so they left it alone and they said she might not have to have the third operation if her vagina stays good… Lately she’s been saying it hurts down there…. It looks fine on the outside…. I’d say all in all she did very well with the surgery.”

Based on other data, I believe this mother, who takes comfort in thinking that the physicians won’t require further surgery, may be overly optimistic. Because parents are not equal partners in the diagnosis (which, of course, they shouldn’t be because they have no medical expertise), they aren’t equal partners in the surgical decision. They take the surgeon’s recommendations as to what kind of surgery to give their child and when to have it as more than just recommendations. I’m not saying that parents are dissatisfied with this arrangement. Given the medical worries some of them have, they are probably relieved to have this aspect of the condition handled by someone else and solved for good. If there is anxiety about whether their child is really a male or a female, that too has been managed and erased by expeditious surgery. Not all parents are successfully socialized to see it the physicians’ way. One mother I’ve been in contact with has a son with the supposedly embarrassing problem of a micropenis. With the support of one physician she opted not to change the child’s gender. His micropenis seems not to be a problem for her. She has no difficulty thinking of her son as male. Intersex surgeries can be traced, in part, to the taking of both gender and genitals too seriously.

Although it’s unlikely mainstream America will embrace a third or fourth category in the near future, I believe people can learn to accept more genital variation. Although doing so will (at least temporarily) maintain the two gender system, it might help unlock gender and genitals. This could ultimately subvert gender by subverting genital primacy. Gender will be shifted from the biological body onto the social interactional one. So even if there are still two genders, male and female, how you do “male” or “female,” including how you do “genitals,” will be expanded. I’d like you to imagine the following communication from an obstetrician to the new parents: “Congratulations, you have a beautiful baby girl. The size of her clitoris is providing a clue to what might be an underlying medical problem that we’ll need to treat. I’ll consult an endocrinologist about any possible medical treatment. Although her clitoris is on the large side, it’s definitely a clitoris. Who knows what it’ll look like as she grows? Some parents don’t have a realistic sense of what a baby’s genitals look like. You probably haven’t seen that many, but I have. No, we won’t need a surgeon, since there’s nothing we need to do about the clitoris. The important thing about the clitoris is how it functions, not how it looks. She doesn’t have a vagina now and she can decide whether she wants one constructed when she is older. Surgical techniques will be more advanced then and her grown body will tolerate the surgery better if she chooses to have it.”

I mentioned earlier that some adults are deliberately altering their genitals, treating their genitals as innate but malleable, much like hair in our culture. Will this lead to greater acceptance of natural genital variability in infants and fewer infant surgeries? I’ll admit that I’m concerned that promoting elective genital surgery could lead to less tolerance of variability, rather than more. The analogy to noses is obvious. People choose the small upturned one, characteristic of the privileged class, rather than a variety of wonderfully ethnic ones. Given that pattern, what will happen if it becomes fashionable to alter one’s genitals? Will this mean that everyone—female and male—will elect to have large phalluses like the privileged gender, or will it mean that males, evoking their privilege, will restrict large phalluses to males and demand that more females have their clitorises reduced? This is a risk we need to consider as we express tolerance for adult genital experimentation. Everything hinges on our understanding that there is no one best way to be a male or a female or any other gender possibility—not even in terms of what’s between your legs. Accepting genital variability will need to occur in the social context of accepting gender variability. And in that acceptance lies the subversion of both genitals and gender.