More Evidence People Did Well without Surgery!

Classification: News

This comes from Christina Matta, author of a very interesting new article on the history of intersex: “Ambiguous Bodies and Deviant Sexualities: Hermaphrodites, Homosexuality, and Surgery in the United States, 1850-1904,” Perspectives in Biology and Medicine, vol. 48, no. 1, Winter 2005. We asked Ms. Matta to summarize for our visitors what she learned about whether people with intersex faired well or poorly in the era before pediatric “normalizing” surgeries became standard practice. Here is what she wrote:

To anyone who understands that intersex genitals are not a life-threatening condition, the predominance of childhood “normalizing” surgeries as a medical response to atypical anatomies is completely inexplicable. It is even more inexplicable given that historically, adults with intersex were, by default, completely in control of their anatomies. Even if they had reason to consult a doctor (and those who did almost always did so for reasons that had nothing to do with their genitals), very few individuals were interested in the “solutions” doctors spontaneously offered. In the first half of the nineteenth century, in fact, all doctors could do was tell patients that they were not the sex they thought, and to order them to stop wearing pants (or to start wearing pants!) or otherwise act according to more appropriate gender roles. (In Hermaphrodites and the Medical Invention of Sex, Alice Dreger tells the story of a Belgian doctor who, in 1886, exclaimed after examining his patient, “But my good woman, you are a man!”) But this was the extent of medical treatment for intersex, and there’s nothing to suggest that patients bothered to do as they were told.

Surgery entered the scene around the mid-nineteenth-century in the U.S. In 1849 Samuel D. Gross, a prominent Philadelphia surgeon, removed a testicle from a three-year-old girl whose parents had become concerned about her “boyish” behavior. He published an account of the surgery in 1852, claiming that he hoped it might serve as an example for other physicians if they were ever faced with similar cases. But physicians – even those trained specifically as surgeons – didn’t rush to offer, much less to perform, surgery to correct atypical anatomies. American medical journals published 41 reports of hermaphroditism between 1852 and 1879, but only three mentioned surgery: Gross’s report; one published in 1868 in which a woman requested the removal of a tumor that turned out to be a testicle; and a third from 1869 in which a physician attempted to correct hypospadias in a young child.

The number of surgeries performed picked up a little after 1880. I’ve argued elsewhere that this was because homosexuality first appeared in medical literature as a medical (and moral!) problem, rather than a weird behavioral quirk. Physicians had always been interested in so-called hermaphrodites’ sexual behavior, but now the idea that patients might be engaged in homosexual behavior gave them something else to worry about. As a result, more physicians began to suggest surgery to patients as a means of curtailing their sexual behavior. Their reasoning was quite convoluted, but had to do with the assumption that no matter with whom their patients chose to express their sexuality, it was automatically a homosexual relationship. A patient with a predominantly female anatomy or appearance but male gonads having sex with a man? Homosexual, because of the male gonads. But a patient who was predominantly female and had male gonads having sex with a woman was also homosexual, because the patient was predominantly female.

Furthermore, physicians feared, patients might try to have sex with both men and women, which was a sign of a fickle sexuality and, in doctors’ minds, a greater degree of moral degradation than even homosexuality. The only way to prevent both homosexuality and bisexuality, many physicians agreed, was to “castrate” patients altogether to try to prevent them from engaging in any sexual activity. It is not clear if physicians used these arguments when speaking with their patients directly (it seems unlikely, however), but as the number of journal publications that urged surgery increased, so did their vehemence that intersex patients should not be allowed to engage in sexual behavior. Gross even argued that preventing intersex patients from having sex was an act of mercy, as such acts would surely result in embarrassment for everyone involved.

At no point in the century, however, did patients predominantly agree to surgery just because their doctors suggested it. Again, patients rarely went to the doctor complaining of their unusual anatomies. Rather, they went complaining of stomachaches or hernias, and when doctors discovered what seemed to be anomalies – testicles in women, labia or vaginas in men – they encouraged patients to consider surgery. But doctors’ entreaties notwithstanding, patients often shrugged off their uncommon bodies as harmless and went about their business as usual. One example of this stands out in particular: in 1880, a forty-six year old Irish woman approached a doctor at the New York City for the Ruptured and Crippled for a truss to contain a double hernia. Upon examining her, the doctor discovered two labial tumors that were connected to cords resembling spermatic cords and suspected that they were testicles, even though he admitted he found no other physical evidence that she was not a woman. When he offered to remove the tumors, the woman declined – or, as he described her reaction, she “refused to have any operation performed,” – claming that “she suffered no inconvenience” from their presence. The woman was obviously content with her body.

I do not mean to suggest that intersex patients never chose surgery, but rather when given the choice, adult patients declined far more often than they accepted. There was one notable exception to this: in 1904 a young woman identified only as E.C. approached a New York gynecologist, for an examination. E.C. she had facial hair and a vagina - though the doctor could find no ovaries or uterus - and a clitoris that resembled a penis in size and shape. She claimed that she wanted this structure removed because it was, in her words, “annoying.” The doctor obliged by removing her clitoris and using its skin to expand her vagina. Eight months later, he examined her again, and marveled at her physical recovery and her buoyant mood.

This case was controversial for other reasons (mostly having to do with E.C.’s sexual behavior, and I’ve described this in my paper, cited above), but it stands out against both late nineteenth- and twentieth-century medical responses to intersex because E.C. requested surgery of her own volition. Furthermore, her doctor asked her which sex she would prefer to be before performing the surgery. This was no more common in the nineteenth century than it has been in the twentieth, but this example – and the broader historical context in which it sits - provides three striking lessons from which today’s medical practitioners should learn:
• first, that many individuals with atypical bodies have lived perfectly happy, fulfilling lives without any need for surgical intervention;
• second, that it is possible for adult patients to make decisions about their bodies based upon their lived experience and how they perceive themselves within traditional models of sex and gender roles;
• finally – and this is most important – adult patients’ consistent refusal of operations meant to “normalize” their bodies shows us that just because surgeons can perform these procedures doesn’t mean that they should.