Tuesday, September 9, 2014

Trans-Exclusionary Radical Feminists and Intersex Experience

Recently I spent several days in a public internet group for "gender critical" people, after a few intersex friends voiced some positive things about this line of thinking.  Feminists who call themselves "gender critical" are a controversial bunch, but their critique of the term "cis gender" had caught the interest of some intersex people I respect.  The term "cis gender" is an awkward one to use in the context of intersex people, which was the subject of my last blog post.  So I wanted to approach this branch of feminism with an open mind, and see if there was theorizing or political advocacy I could use in my intersex work.  The group I joined promised respectful listening to people of varying beliefs, and banned personal attacks, so I had high hopes.

My hopes, I'm afraid, were naive.  The group turned out to be completely dominated by "TERFs," trans-exclusionary radical feminists, and when it came to intersex topics, not people I would consider good allies in the least.  So, since I know there are other intersex advocates who've presented "gender critical" politics in a positive light, I wanted to write a post about why I consider this a bad idea.

First, since I suspect that a good number of readers may be unfamiliar with the terms "gender critical" and "TERF," I will present an overview of the beliefs involved, in the form of a handy numbered-list primer.

A TERF Primer

1.  Calling themselves "radfems" or "gender-critical feminists," and named TERFs by radical-feminist-identified people who are not transphobic, these are cis women who oppose the inclusion of trans women in feminist organizations, women's spaces, and female facilities.  TERFs do not describe themselves as cis women, however, but as women-born-women, natal women, or (unmodified) women.  They assert that the terms "TERF" and "cis" are slurs.  Generally they just refer to one another in discussions as "feminists" and as "women," as if anyone who is a feminist would agree with all that they say, and as if their female status should go unmarked, as the normative or "real" female status.

2.  Trans-exclusionary radical feminists believe that sex is a natural binary, innate and immutable: men have penises, women have vaginas and uteri.  They note that gender is a relationship of power, in which men seek to control women's uteri, reproductive capacities and lives.  The ultimate expression of this patriarchy is the use of the penis to rape.  As a result, "gender critical feminists" make the strong claim that anyone who denies that sex is a binary and that genitals determine gender is ignoring the terrorizing of (natal/cis) women by rapists.

3.  TERFs argue that sex cannot be changed: trans women are really and eternally men, and trans men are really and eternally women.  Identifying with a gender that doesn't match one's genitals is a delusion or mental illness.  The phrase "gender critical" denotes being critical of (or more bluntly, rejecting) the concept of gender identity--most especially the fundamental precept of trans gender advocacy, which is that when gender identity and legal sex conflict, this provides pragmatic and ethical justification for a change of legal sex.

4.  TERFs deny that they are transphobic, and say they have compassion for men under the delusion that they are women, which they present as equivalent to believing one is really a horse or a space alien.  Dysphoria with one's body, they point out, is not a special characteristic of trans people, but a near-universal, and the solution is to accept one's body.  Accepting one's body means accepting that one cannot call oneself a woman while having a penis.  (Nor can sex be altered through genital reconstructive surgery , which is a radical mutilation to no purpose, as genes can't be changed and binary sex is essential.  But in most of the discussion threads I read, it was assumed that trans women all have penises, making them dangerous, as penises are rape weapons.  In fact, I've never read the word "penis" so often outside of a urology blog.)

5.  TERFs are not just binary sex essentialists, they also have a theory of gender socialization.  Their vision of gender socialization is bleak: boys are socialized to dominate, control, and rape women; girls are socialized to submit to this and embrace their oppressors and call this "femininity."  Clearly this is bad, and feminism is a movement of (natal/cis) women that teaches women to recognize and resist this programming.  Men, however, are presented as inevitably and eternally shaped by their socialization into patriarchy, as it advantages them.  Trans women are men, and while they may claim they do not enjoy being treated as men, this just illustrates their blindness to their own privilege.  Trans women are inevitably socialized to try to control "natal" women, as evidenced by their belief they should be able to force cis women into supporting their gender delusion and treating them as sisters.

6.  Thus, this conclusion about trans people: trans women are confused men, fetishists of the feminine, who are prompted by their male socialization to seek to control women--in this case, due to their delusion that they are women, to control feminism and women-born-women's spaces.  Trans men are less of a problem, since they pose no threat to anyone, lacking both penises and socialization into the role of the oppressor.  Trans men are just sad: women who don't understand that it's ok to be a butch woman or a lesbian, victims of Stockholm syndrome identifying with their oppressor.  Women who are deluded into thinking they are men should be pitied and exhorted to return to the fold.  But men who delude themselves that they are women are a serious problem.  They must be stopped: with exclusionary policies, taking back feminism from a trans-obsessed trend; by fighting antidiscrimination clauses that would let trans women and girls use women's bathrooms; through telling the world that supporting trans children in their identities is child abuse.

7.  Feminists who are trans allies and transfeminists counter each of these points.  They state that sex is not a natural binary, but naturally a spectrum (i.e., intersexuality happens).  They point out that many cis women lack uteri, yet are still considered women by everyone, even TERFs.  They note that gender socialization is complex and variable, that it is shaped by the gender with which one identifies, and that acknowledging both these facts is in no way a denial of the reality of patriarchy.  They assert that it is important, however, to acknowledge the intersectional nature of marginalization and privilege, and speak not just of patriarchy but of kyriarchy, taking into account race, age, sexual orientation, (dis)ability, and other dimensions along which power is distributed.  And one of these dimensions is the axis of cis privilege and trans marginalization.  Trans women--particularly those who are poor, of color, and/or have a disability--suffer huge levels of social stigma, violence, employment discrimination, etc.  Cis women need to acknowledge that while they are marginalized as women, they are privileged as cis people.

8.  TERFs respond to trans allies with anger.  They say trans allies are dupes, following a trend that counters basic logic, biology, nature, and the English language when they accept the idea that a person with a penis can be called female.  (Quoting the dictionary is popular to "prove" that genitals determine gender.)  They discount all the statistics about violence against trans women (and to a lesser extent trans men) as manufactured and overstated.  They assert that a woman can never oppress a man, and trans women actually being men, "natal" women cannot oppress them.  The TERFs repudiate being termed cis gender, equating the term "cis" with gender-conforming and unenlightened femininity, and regularly linking it to the violent phrase "die cis scum," which they assert is the core sentiment of men who think they are women, as if trans women's goal is to kill off all cis feminists so that trans women can have every feminist organization that exists all to themselves.  Finally, they equate acknowledging cis privilege with asserting a belief that women are not oppressed.

Intersex People and "Gender Critical" Politics

It's clear that I view TERFs, in a word, as bigots.  Their mission is to discriminate against and exclude a marginalized group.  I hoped I might encounter something less stark and more nuanced in the "gender critical"internet discussion group I joined, since some other intersex advocates have had some positive things to say.  But that's not what happened, and a couple of days spent reading and attempting to have conversations left me feeling depressed and sullied.  There were a few positive moments, but they were vastly outweighed by slogging through a lot of LOLing about how stupid a person must be to think they can call themselves female when they were born with a penis.

So, my first question is, why have a few intersex friends had anything good to say about TERFs?  I think I can point to a few things.

1.  The phrase "gender critical" sounds appealing.  My intersex friends are critical of the way sex and gender are understood and enforced in the contemporary West, since this involves unconsented-to surgery performed on intersex infants' genitalia with lifelong ramifications that can be quite negative (loss of genital sensation, loss of fertility, loss of a source of natural sex hormones, and sometimes assignment to a sex with which the child does not grow up to identify).  A group that says they critique gender from a feminist perspective certainly sounds like it would make a reasonable ally.

2.  Intersex people are often uncomfortable with the application of the terms "cis" and "trans" to intersex experience.  The terms apply very poorly because they presume that physical sex is binary (even if gender identities may be nonbinary).  That is, if a person is born genitally intermediate, surgically assigned female, and grows up to identify as a woman, is she "trans gender" because she was surgically genitally altered to become female, or "cis gender" because she identifies with the sex she was assigned at birth?  Either term winds up misrepresenting something about her experience.  (I've suggested the term "ipso gender" in my last post as an alternative.)  In any case, TERFs reject the term cis gender, and this may appeal to an intersex person frustrated with this terminology.

3.  In recent months, there have been a series of "mainstream" articles and online posts in which TERFs' positions have been sympathetically expressed.  For example, one article mentioned by an intersex friend critiqued the term "cis privilege" by caricaturing it as meaning "having a female body is a privilege."  Clearly this is false: because of patriarchy, female bodies are sexualized, framed as weak, and subjected to surveillance.  Tons of cis women don't enjoy getting periods or feeling constantly at risk of an unwanted pregnancy.  Having a female body is not a privilege--but it is also not how trans advocates define cis privilege at all.  Trans people actually define cis privilege as "the benefits one derives from being seen as a 'real' and 'natural' member of one's identified sex" (lack of public scrutiny of one's primary and secondary sex characteristics, being able to use a public bathroom with relative ease, having an ID that matches one's identity, etc.).  Nor do trans people deny, as the linked article claims, that cis people also suffer from gender policing.  Someone who identifies as a woman yet who is very butch can suffer from bathroom panic, and a male-identified person who is quite feminine may face a great deal of street harassment.  That is why trans advocates always fight for laws banning discrimination on the basis of gender identity or gender expression.  But if you read the linked article and took it at face value--why, the arguments of trans women sound regressive and ludicrous and enforcing of binary gender stereotypes.  Trans women are telling "natal" women their privilege is to enjoy being pretty and silent and submissive and having lots of babies, says the author!  If that were true, transfeminists really would be revealed to be patriarchal oppressors in disguise.  Only. . . it's not true.  It's a false characterization on par with saying that "feminists are man-haters."

OK, now we have some ideas about why intersex people might think that "gender critical" camp could be reasonable allies for intersex people.  The next question to address is what did I actually find TERFs to say about intersex issues when they were raised in group discussions?  Clearly the "gender crits" aren't trans allies, but are they nonetheless intersex ones?

The first thing I really want to acknowledge is that it's not all bad.  A couple of points came up where "gender critical" positions did align with intersex advocates'.  Most centrally, since TERFs believe that the "natural" sexed body should be accepted rather than medically altered, a good number of commenters were opposed to performing genital surgery on intersex infants, seeing it as mutilation.   That's a good thing.  And secondly, when I posted about Dutee Chand, an athlete who has been excluded from international sports due to sex-policing of her natural levels of testosterone, I found that at least in situations in which a person was born with vulva, raised as a girl, and has XX chromosomes, the TERF posters believed she should be allowed to compete in women's sports despite having testosterone levels that were considered "male."  Also good!

Well, those positions sound heartening!  Why then do I say that the "gender critical" partisans are not good allies for the intersex community?  Because of these numerous other positions of theirs:

1.  There was a total consensus among the trans-exclusionary feminists that sex is naturally a binary.  The fact that people are born sexually intermediate was somehow said not to undermine this assertion, because intersexuality was presented as a disorder, and, I was informed, "you can't take a disorder and call it a sex."  All intersex people were held to have a true binary sex.  While doctors shouldn't perform cosmetic genital surgery, TERFs asserted they should examine the infant and assign them to the correct binary sex on their birth certificates.  I was told that the correct sex would be based on capacity to reproduce in the "very rare" situations in which that would be possible without surgery, and otherwise on genes.

2.  Removing sex-markers from birth certificates generally, or making a preliminary sex marker amendable at will at maturity to M, F, or a nonbinary category--as suggested by intersex advocates--were thus framed as crazy.  It could confuse the child into believing they are members of a third sex, while "real" intersex people identify as women or men, discussants claimed.  It was presumed to be bad for intersex children, while encouraging trans genderqueer fantasies.  Since TERFs see gender identity as a sort of delusion or myth, the idea that families and society should allow the child to mature to develop and assert their own gender identity (male, female, or something else) is basically incomprehensible. 

3.  Nobody on the site at the time I was on it seemed aware what the result of the sex assignment scheme they described would be.  For example, people with CAIS, born with typical vulvae and developing female secondary sex characteristics at puberty if unaltered by gonadectomy, would be understood as permanently and naturally male, being infertile and having XY chromosomes.  Yet CAIS is often not diagnosed until late childhood or puberty, so either CAIS teens would be forced into gender transitions--a process the "gender crits" frame as impossible--or the TERFs would have to accept XY women.  Meanwhile, people born with a phallus fully masculinized by CAH would be permanently assigned female based on having XX chromosomes, while left surgically unaltered.  Given that the most central tenet of TERF politics is that a person with a penis cannot be female, this is a particularly strange outcome.

4.  I was surprised to find myself repeatedly informed that "intersexuality is a derail" when I raised concerns in conversations.  One reason for this is that being born intersex was framed as vanishingly rare.  Basically this argument held that half the population is made up of "natal women" under threat from men trans-deluded into thinking they have a right to enter women's spaces, while intersex issues only impact a handful of people, and concerns about a minor edge case shouldn't come to dominate a discussion about masses of women-born-women.

5.  The main reason I was told that TERF group members were "far beyond the point of reasonable frustration or tolerance for the intersex derail in conversations about gender identity" is that it was supposedly "only ever brought into conversations" as a distractor by men (that is, trans women) trying to deny the reality that genitals determine immutable binary gender, that "natal" women are oppressed rather than privileged, and that trans women are privileged rather than oppressed.  The fact that I, who am intersex and not a trans woman, was the person raising intersex issues was glossed over.   Intersexuality is presented as a straw man issue beloved by trans women.

6.  Another thing I was told is that most people claiming to be intersex are actually trans gender pretenders.  Now, I as an intersex advocate have spoken before about there being an issue of "intersex wannabes"out there, a problem for our community when they present physically-impossible stories--such as having been born with a full set of female reproductive organs and a full set of male ones--that contribute to disinformation.  But I do not appreciate being told that most people who say they are intersex are liars, and that the "tiny minority" of people who actually are intersex are being used by these men-who-caricature-women, proof that real intersex people should revile trans people.  I can make my own determinations about the true prevalence of intersex status, and who is supporting or exploiting me.  Not to mention that asserting that most people who identify as intersex are in fact lying itself contributes to disinformation about our community.

7.  The main situation in which intersex concerns were actually treated as relevant was in the context of discussions of trans-identified children.  (A particularly overwrought conversation in the group discussed an article which bore the blaring title "Toddler Aged 3 Assessed for Sex Change at London Clinic," which actually just reported that a 3-year-old was assessed for gender identity issues, not that the child was offered any sort of hormonal or surgical treatment.)  A claim made in the discussions of trans-identified children was that for parents to "indulge" this "fantasy" by bringing them to a clinic to be diagnosed, changing the pronoun they used to refer to the child, and/or having the gender marker on their ID changed was analogous to forcing genital surgery on intersex children, and thus a human rights violation that should be banned.  I don't see an analogy at all, but rather an inversion: forced genital surgery performed on infants violates their autonomy, while validating a child in their gender identity supports the child's autonomy.  I see TERFs appropriating intersex concerns about unconsented-to genital surgery to advance their goals.

So: I followed a recent suggestion that "gender critical" politics might be useful to intersex people, and spent several days reading posts and participating in a group for "gender critical" partisans.  What I found was something that left an awful taste in my mouth: a lot of transmisogyny, a denial of the lived reality of trans people of all genders, and an insistence on an immutable sex binarism that frames intersex people as disordered.  I was told that most people who say they are intersex are trans pretenders, using a tiny minority to advance their nefarious goal of insisting that gender identity should be respected and genitals treated as nobody's business other than the person bearing them and their intimate partners.  And I found the intersex community's concerns being co-opted to vilify parents who support their children in identifying with a gender other than that on their birth certificates.

They may call themselves by the intriguing moniker "gender critical," but I believe these trans-exclusionary feminists make very poor allies for the intersex community.

Tuesday, August 5, 2014

Cis Gender, Trans Gender, and Intersex

Today, the Intersex & the City blog asks, "Is it impossible for intersex people to be cisgender because it is impossible in society to live completely as in intersex person with no male or female legal checkbox?"

In my experience, what you find when speaking with intersex people about this is an interesting split based upon gender identity. Intersex people who do not identify with the binary sex they were coercively assigned at birth tend to see all intersex people as forced to live trans lives. Intersex people who do identify with the binary sex label they were given at birth instead generally see themselves as cis people, and only frame as trans gender those intersex people who gender transition or who assert a nonbinary gender identity.

Personally, as an intersex gender transitioner, I fall into the camp that does not view intersex people living in our society as cis gender, even if their gender identity matches their assigned sex. Intersex children are born neither male nor female, but are forced into a binary sex category by a contemporary social ideology that says this is mandatory. Many are then subjected to infant sex assignment surgery to try to make their bodies conform to their assigned sex. What is that other than a forced sex change? Just because a person grows up to identify with the sex they were assigned at birth does not mean they will feel surgeries they were subjected to were appropriate. Loss of potential fertility and loss of capacity for sexual sensation are prices that they may not consider worth the result of a somewhat-more-sex-conforming body--note that many people who gender transition by choice choose not to get genital surgery. Thus, I believe, framing medical interventions into the reproductive organs and genitals of intersex people as trans interventions, not "corrections," is important, as it will force doctors to give us agency over what is done to our bodies, and prevent them from removing the very sexual features we may most identify with.

The problem with my framework politically is that a majority of intersex people today do live in their assigned binary sexes, growing up as we do in a society in which that is the norm. The percentage of us who mature to gender transition or assert a nonbinary gender identity is much higher than is the case for nonintersex people, although we don't know the exact degree of the difference because doctors are emphatically not collecting data on us, their sex-assignment "failures." Still, a majority do live their lives in their assigned sexes (often completely in the closet about being born sex-variant, as doctors have urged parents to train their children to be). And most such people do not identify at all as "forced to live a transgender life."  That is, they identify as cis gender.

If someone says, "I was assigned female (or male) at birth, and I identify as female (or male)," then we usually call such a person cis gender. So intersex people who understand themselves as cis gender have a very valid basis for framing themselves that way. Certainly this is the way the medical field treats the situation, in claiming to assign us to what they used to call our "true" sex, and now call our "best" sex. Doctors view themselves not as imposing sex changes upon unconsenting infants, but as revealing our "real" binary (cis) sex.

I feel that understanding all intersex people who have been assigned a binary sex (which, in the US today, is all of us) as trans is useful, because it gives us a way to oppose unconsented-to infant genital surgeries. I view those intersex people who are happy in their assigned sexes as no different from people who are not intersex, but gender transition by choice and are happy as a result.

At the same time, I don't feel I have a right to tell an intersex person who identifies as cis gender that they can't do that.  After all, as trans gender advocates note, every person is coercively assigned to a binary sex at birth. A person who grows up to identify as genderqueer, or with the binary sex they were not assigned, is forced to struggle with medical and legal and social forces to have their identity recognized, whether sex variant by birth or born with a body considered normative.  So, viewing all cis people as coercively assigned to the sex with which they identify makes calling intersex people who identify with the sex they were assigned "cis gender" reasonable, from a trans-affirming perspective.  (Of course, many people are not trans-affirming, and transphobia can motivate rejection of being labeled trans gender.  But I do not believe it is either charitable or necessary to assume that an intersex person who identifies with their birth-assigned sex and rejects being labeled as trans is motivated by bigotry.)

I just feel that labeling anyone who is medically altered to change the sex characteristics of their body as trans makes the most sense, and is useful from an advocacy standpoint.


I've done some additional thinking about this topic, and would like to have people consider approaching gender identity in intersex people by acknowledging that we can never address intersex experience well through binary terminology.  What we may really need to do is to introduce another term.

what I would suggest doing is adding to the terms "cis" and "trans" another term often used in scientific terminology.  In chemistry, which gives us the language of cis and trans isomers, there are chemicals based upon a ring structure, called arene rings. When a chemical substitution is made in the same place on the ring, this is referred to as "ipso" substitution.

If we were to add the term "ipso gender" to trans and cis gender, we could perhaps describe intersex experience more accurately. A cis gender intersex person would be one with an intermediate gender identity, since that "matches" their birth sex. An ipso gender intersex person would identify with the binary sex they were medically assigned (the social sex substituted for their intersex birth status being the same as their identified sex). And a trans gender intersex person would be one who identifies with the binary sex other than the one they were assigned by doctors.

This terminology solution is not without its drawbacks. Usually people who are genderqueer in identity are considered to fall under the trans umbrella, but in the case of intersex people, they'd fall under the cis heading, which could prove confusing. But it's also possible that confusion would itself prove productive.

It's certainly worth considering.

Tuesday, April 29, 2014

On Eugenic Abortion of the Intersex

A century ago, eugenics, the science of breeding "better" humans, was considered the "queen of the sciences." Then came the Holocaust, in which millions of Jews, LGBT+ people, people with disabilities, "Gypsies" and others were murdered by the Germans in the name of purifying the Aryan race.

The first to be sent to the gas chambers were those deemed "lives not worth living": people with disabilities and "deformities."

Germany lost WW II, and afterwards, eugenics was abandoned in the polite sciences, and replaced with genetics. No longer was it considered ethical to speak of breeding better humans by eliminating "undesirables;" instead, genetics was to improve life by addressing itself to pure science or to curing medical suffering.

But eugenics never really went away, and it's operating today through various reproductive technologies such as selective implantation of embryos, and, quite commonly, through prenatal screening for "disorders," which are then "treated" via "therapeutic abortion." Among those characteristics that can been screened for and eliminated are those forms of intersexuality with a genetic origin.

Our medical ethicists today state that selective abortion of female embryos is unacceptable, because there is no medical condition, simply a social preference. Yet termination of pregnancies involving intersex fetuses is deemed ethical, because we are deemed disordered. In essence, this "ethical" position is that it's ok for doctors to select fetuses with disabilities for termination, as it's rational for us to be considered "lives not worth living."

OII Australia has submitted the following comment on guidelines for the use of assisted reproductive technologies in Australia, which you can find here. It argues that intersexuality is not a "disorder," but rather a natural variation. It further argues that medically selecting against intersex pregnancies is akin to selecting against female pregnancies, being based on social biases, and should be considered unethical.

I'm all for that, but I'd go further. I'm pro choice, and believe a pregnant individual should have the ability to terminate an early pregnancy at will, based on her assessment of her readiness and ability to carry a pregnancy to term. But I have grave moral reservations about eugenic abortion--a termination of a pregnancy based on the characteristics of the fetus as determined by doctors. Elective abortion at will relates to people's reproductive autonomy, but eugenic abortion focuses on what types of people are considered valuable or disposible. And, as someone who is Jewish, LGBT+, and intersex, I see a clear continuity between my being a candidate for the gas chamber were I living in Nazi Germany, and my being a candidate for selective abortion were I conceived today. I cannot countenance eugenics.

Thursday, April 10, 2014

Testosterone and the Sex Policing of Athletes' Bodies

New policies for Olympic and other international athletes set an upper limit to the amount of testosterone considered "normal" for a woman, and require those women who have natural levels of T that are higher than this to have medical interventions to lower their levels. If the women are found to be intersex, these interventions include surgical removal of their gonads, and (though this has NO relation to testosterone production) surgical reduction of their clitorises if these are deemed "enlarged."

This is just crazy. Some facts: first, levels of testosterone vary a lot. Tests of elite athletes show that about 17% of male athletes have testosterone in the "female range" and 14% of female athletes have testosterone in the "male range." Secondly, there is no direct correlation between levels of T and athletic performance; that's simplistic and nearly magical thinking. And third, it makes no sense to define the range of "normal" T levels for women very narrowly (15 - 70 ng/dL) and for men very broadly (300 -1,000 ng/dL), in essence saying that there's no such thing as a natural level of testosterone too high in a man, but there is such a thing for a woman.

Bodies vary a great deal. Why do we focus obsessively on policing the sexed body of athletes, rather than on other "abnormalities?" Basketball players are abnormally tall, which actually does enhance their performance. Many gymnasts are double-jointed and abnormally flexible. In fact, most any sport rewards people with atypical bodies, and we *celebrate* that. But when it comes to sex variance, a variation that is associated with high performance more in fantasy than in fact is suddenly subject to extreme bodily policing, and that's just wrong.

Saturday, December 21, 2013

A Seasonal Thought

Apparently 0.8% of American mothers report that they became pregnant as virgins.

The likelihood that some of these mothers had in fact had classical penile-vaginal intercourse, but didn't wish to report it, is indicated by the fact that these self-proclaimed virgin mothers were twice as likely to have taken an abstinence pledge than were other mothers.

But others of these virgin mothers were likely telling the technical truth: that they had not yet engaged in penetrative intercourse when they became pregnant. Sperm, you see, swim, and if they are deposited on the exterior of a person's body, they can make their way inward all by themselves. Thus, pregnancies regularly result from "outercourse."

As an intersex person, I think about this a lot, because doctors often claim that genital surgery is not cosmetic but functional, as without an "adequate" vagina or "repaired" penis, we will be infertile. To which my sophisticated academic rebuttal is: nuh uh! You need the right hormonal balance to go with the gametes, and some way in or out, but it certainly doesn't need to be a vagina that can "accept" a penis, or a phallus that is large and has the urethral opening at the tip.

Wednesday, February 20, 2013

Hypospadias: Intersexuality and Gender Politics

If you are looking around for information about intersexuality, one of the first things you're likely to read is that "most intersex children are assigned female at birth."  This is in fact false.  

In the U.S. today, according to the CDC, one in 125 children assigned male at birth is surgically modified to fit that binary sex status.  The percentage of children assigned female at birth who are genitally altered in infancy to feminize their genitalia seems to be lower.  Exactly how much lower is very difficult to determine, since nobody is gathering the data we'd need to have.  The reason we know the 1-in-125 figure is because these children assigned male are all given the same diagnosis: hypospadias.  Hypospadias is the diagnosis given to most children born with intermediate genitalia who have external testes.  Rates of hypospadias have been increasing, and the CDC is collecting data due to concern about that.

The reason people continue to say that few intersex individuals are assigned male is that doctors term hypospadias a "penile malformation" rather than an "intersex condition."

I've written about this before in this post.  I noted there, "medical diagnostic categories are not logical, despite our ideology that they should be so. The majority of individuals born with intermediate sexual anatomies [and surgically assigned male] are not given an intersex diagnosis. I believe that what underlies this is gender ideology. And that gender ideology is this: masculinity is fragile, especially when it comes to what a man has in his pants. To live as a man with an inadequate penis is seen as intolerable. To have one's status as a 'real man' challenged is viewed as psychologically crushing. Thus, doctors feel, if they were to categorize someone as intersex and then assign them male, they would be acting cruelly.  Women, on the other hand, are perceived as more gender-flexible. After all, it's reasoned, a woman isn't shamed by wearing pants or taking on a power career. [Doctors view] female-assigned people as more comfortable with androgyny and as better at dealing with emotional challenges."  Because of assumptions about fragile masculinity and flexible femininity, doctors feel more at ease assigning children they designate as intersex female. Those they regularly surgically alter to conform to binary male sex norms, they wish not to label intersex.

I was contacted by some people after writing that prior post challenging my assertion that hypospadias is an intersex condition.  They countered that it was simply a minor displacement of the male urethra.  So I wanted to make my case more clearly.

Let's start with some illustrations.

All children start out in the womb with the same set of genitals, an intersex form.  As a rule I will not post photos of children's actual genitalia because it is exploitative, but in this case, I feel a medical image of the standard genital form of a fetus isn't going to cause additional emotional trauma to any particular child, so here's a photo:

Our society expects this intermediate genital form to differentiate before birth into two "opposite" binary sex forms (penis and testes, or vulva), but in fact, babies are born with genitals on a full spectrum between these two socially idealized poles.  Let's look at how medical professionals illustrate this sex spectrum.

When a child is diagnosed as having some form of XX, CAH, congenital adrenal hyperplasia, the sex spectrum is described by the "Prader scale," and the "stages" of the "condition" evaluated using this chart:

When a child with XY chromomes is diagnosed as having a form of AIS--partial or complete Androgen Insensitivity Syndrome--the sex spectrum is termed the "Quigley scale," and is illustrated like this:

You can see that both of these illustrations include 6 forms, although they number them in reverse order and with different numerals.  What they both show is that between a genital form considered typically female and one considered typically male, there is a common spectrum of intermediate forms.

This is equally true for children who are diagnosed as having hypospadias.   But medical illustrations of hypospadias are very different.  They do not picture the genitals as intermediate in form.

Instead of picturing the same range of in-between forms shown in the Prader and Quigley scales, medical illustrations of hypospadias variations show something odd: a carefully illustrated "normal penis" with a series of dots superimposed upon it to indicate the level at which the urinal meatus/ vaginal opening are located.  

The penis is always illustrated as erect, and often with a lot of illustrative detail to emphasize the "reality" of this imaginary ideal penis existing instead of the intermediate genitals actually present in intersex individuals who have external testes.

Let us be clear here.  A child diagnosed with hypospadias of an "advanced degree," be it termed perineal or posterior or scrotal, will have an intermediate phalloclitoral form with a substantial invagination, not a large, erect phallus with a dot at the bottom.  They'll look more like the Prader 2 or Quigley 4.  I'd illustrate such a child's genitals more like this:

Why would medical illustrations of intermediate genitalia be representationally accurate in the case of intersex children diagnosed under the rubrics of AIS or CAH, but inaccurate if highly detailed in the case of intersex children diagnosed under the rubric of hypospadias?  Only gender ideology can explain this.  Children diagnosed with CAH and AIS are routinely assigned female.  But children with hypospadias are surgically "corrected" to male, and to undermine the "adequacy" of a male's phallus is treated as untenable.  Parents (and doctors!) must be reassured by looking at the erect, large, ideal penises drawn in the hypospadias illustrations that the genitally intermediate flesh of the child they see is illusory, and that an excellent penis will soon be revealed by the scalpel.  

So: medical illustrations of hypospadias, and the medical assertion that it is not really an intersex condition, relate to our ideologies of masculinity.

The differences in medical approaches to intersex children routinely assigned female and routinely assigned male extend further than illustrations and terminology.  They also determine all the tests and evaluations the child will receive.  If an intersex child lacks external testes--the determining characteristic of a hypospadias diagnosis--that child is routinely subjected to a battery of tests: genotyping, endocrine screening, medical imaging scans.  This is not the case when an intersex child has external testes.  In fact, even suggesting that a child with intermediate genitalia but palpable testes receive any sex-related tests at all is considered "controversial" by doctors.  Since hypospadias is defined as a penile malformation that is not an intersex condition, why would anyone wish to test sex chromosomes, hormone levels, or internal reproductive structures?  It's presented as an unacceptable waste of time and money, in an affronted tone.  

In fact, individuals born with hypospadias do commonly have other sex-variant characteristics.  An example is the presence of what is termed a substantial "prostatic utricle," a uterine structure that may be small or full-sized that connects to the vaginas present in these children at birth.  While the "pseudovaginae" are removed and closed during infant genital "normalizing" surgery, doctors do not test for the presence of a uterine structure.  People diagnosed with hypospadias and their doctors generally only become aware that there is a utricle present if something goes wrong, such as the development of uterine cancer or painful cysts--and then usually by accident during imaging scans for some other presumed cause of the patients' symptoms. 

I want to note that many intersex people assigned female at birth complain of all the invasive tests and screenings and procedures to which they are subjected in childhood, so the fact that intersex children with hypospadias diagnoses avoid these is not necessarily a bad thing.  But not even thinking of checking for a uterine structure in someone born with hypospadias who presents to a doctor with pelvic pain could have very negative health consequences. 

It is clear is that intersex children diagnosed with hypospadias are treated very differently than children with other intersex diagnoses.  Rather than being treated as bizarre and interesting medical cases that require a lot of medical study and intervention, they are treated as normal boys with a little urethral displacement issue.

The thing that children diagnosed with hypospadias have in common with other intersex children is that they are subjected to genital normalizing surgery that can have many negative consequences.  Medical texts list as unwanted consequences of hypospadias "repair" surgery urethral fistulae, strictures, and diverticulae, recurrent urinary infections, "excess skin," hair-bearing skin, persistent chordee, erectile difficulties, erectile persistence, chronic inflammation, and a condition called balanitis xerotica obliterans.  Textbooks are oddly silent on the issues of loss of genital sensation that are very common, and the fact that children born with genitals in the middle of the sex spectrum are particularly likely not to identify with the sex they are surgically assigned at birth.

Some children who are diagnosed with hypospadias have genitals that are quite close to the binary male ideal in our culture.  For them, medical interventions may be fairly minor, and the side effects may be modest.  They are very likely to see themselves as typical males, and are probably unlikely to wish to be identified as intersex because they share our society's pattern of fragile masculinity.  I am empathetic with their position.  But we should be able to support the gender identities and dignity of people born with hypospadias who identify as men without resorting to inaccurate medical illustrations and illogical medical taxonomies.  

Hypospadias is an intersex condition.  The surgeries we perform on unconsenting intersex children without their consent have lifelong consequences.  These can be profoundly negative for children whose genitals are dramatically altered--something that intersex advocates decry all the time.  But we should also question why we routinely risk the loss of sexual sensation in the glans of the male-assigned child whose urethra is in a slightly atypical place.

All of us born intersex deserve to be recognized as such, and to be granted autonomy to make our own decisions about what "normalizing" surgical alterations we wish, if any.  Putting an end to the routine genital reconstructive surgery performed on the many thousands of children diagnosed with hypospadias each year should be considered an important point of intersex advocacy.

Wednesday, January 2, 2013

Just-So Stories about Hermaphrodite Fish

A central issue that makes life hard for intersex people is invisibility.  Most people are unaware of how common intersex individuals are, something I’ve often discussed on this blog.  But there’s a larger setting in which the fact that sex is a spectrum gets erased, and that’s in descriptions of biology and the animal kingdom as a whole.  One way this happens is when biology textbooks fail to mention the fact that instances of intersexuality are found in all animals.  Another way it happens is through what we’re taught about those species in which hermaphroditism is the norm.  It’s the latter that I want to illustrate for you today, by examining about how we talk about a fish, the bluebanded goby. 

The bluebanded goby is a small and colorful fish, bright orange-red with iridescent blue stripes.  Bluebanded gobies are hermaphrodites, with the ability to produce either eggs or sperm.  Each bluebanded goby can switch from producing eggs to sperm or vice versa in the space of about two weeks; externally, there’s very little difference between an egg-laying or sperm-producing bluebanded goby.  They have a “sexual papilla” through which they can release egg or sperm, and it is a bit pointier when in sperm-producing mode and a bit wider in its opening when in egg-laying mode.   Most bluebanded gobies spend most of their lives in egg-laying mode.  They live in mating groups, and typically only one member of each group produces sperm, with the rest laying eggs, maximizing the number of offspring the mating group can produce.  It’s a neat arrangement.  It’s also not one that you’re likely to hear about if you are visiting an aquarium or keeping fish.

The intersex nature of the bluebanded goby is erased or distorted in most descriptions of the fish, because our society is so invested in the idea that sexual dyadism is natural and universal that we can’t see evidence to the contrary right in front of our eyes.  We don’t hear about it in our educations.  Say, for example, you’re a schoolchild going for an educational trip to an aquarium, and you see the pretty gobies there.  Here’s all you’d learn at the Cabrillo Aquarium in San Pedro, California about the sex of bluebanded gobies: “Recognized by an elongated robust body and two dorsal fins, males have longer dorsal spines and a suction-like disc that is formed by the connection of its pelvic fins.”  (See here.)  You’d hear yet another example of the “natural, universal fact” that all animals are male or female, not evidence of the sexual diversity of the natural world.  Not only does the hermaphroditism of the gobies go unmentioned, the “masculinity” of bluebanded gobies in sperm-producing mode is exaggerated—they are said to have “longer dorsal spines,” a phallic and aggressive description of a nonexistent difference.  In fact, scientists determining whether a bluebanded goby is in egglaying or sperm-productive mode do not look for any difference in dorsal spine length, only at the shape of the sexual papilla.  (Generally, a sperm-producing bluebanded goby will be on the large side for the species, and hence will have largish fins—but egglaying bluebanded gobies that are large have the same size dorsal spines, and the dorsal fins on a given fish do not change size when it moves between egglaying and sperm-producing modes.)

When popular educational sites do mention sex variance in the bluebanded goby, they don’t explain the fact that all bluebanded gobies are hermphrodites, capable of producing eggs or sperm.    They instead tell a story of rare and fascinating “sex changes” in fish that are otherwise binary in sex: “Males and females are similar in coloration, however, males have a longer dorsal fin than the females do. One interesting fact about blue-banded gobies is that if there is no male present, the dominant female in a group of blue-banded gobies has the ability to change her sex to that of a male.”  (See here.)  This description frames bluebanded gobies as sexually dyadic, existing as males and females, except for the occasional female who goes through a “sex change” in desperate times.  The fact that all of the bluebanded gobies are hermaphrodites, and that each time they move from group to group they have the ability to move from egglaying to sperm-producing mode or vice versa, goes unmentioned.  Rather than undermining the ideology of a natural sexual binary, the story of the rare “sex change” actually bolsters it.  “How bizarre and rare is this deviation, a one-time move between natural binary sexes!”

Not only do educational sites teach that bluebanded gobies are almost always “normal males and females” rather than always hermaphrodites, the way they present goby “sex changes” reflects ideas about human gender roles.  The BBC Science and Nature website states that bluebanded gobies “live in small groups with a single male and multiple females.  If the male leaves or dies, the largest female changes sex.”  (Link here.)  The story is one of a large, dominant male with his harem of smaller females, and a burly female fish changing sex to “rise” to male status and take over the harem.  This is how the story is told by most scientific articles about bluebanded gobies that’s I’ve seen.  Let me quote a passage from a 2005 article in the Biological Bulletin on “sex reversal” in bluebanded gobies, so we can examine this in more detail:

“Larger size often equates with increased success in aggressive encounters and therefore social dominance, providing a proximate mechanism for the size advantage hypothesis. In protogynous sex changers, the most reproductively significant resource that dominance affords is “maleness”; thus the reproductive payoff for dominance is extremely large, and females would be highly motivated to increase their aggressive behavior in times of social instability (i.e., in the absence of a dominant male).”  (See here.)

I’ll now restate that passage in clearer English and make overt its hidden assumptions: “Sex is binary but in some rare species ‘sex reversal’ can occur.  When it does occur, it is from female to male, because everyone knows it’s better to be male.  To be male is to be dominant and aggressive, which is good.  Usually in species where ‘sex reversal’ can occur, males keep the females in their place, but if there’s no male around, the females will all want to battle because the winner will get to be the male.”  This just-so story reaffirms all sorts of human gender stereotypes—and in so doing vastly distorts the objective reality of bluebanded goby life.

The first way the scientific fable distorts reality is by calling hermaphroditic gobies “males” and “females,” imposing binary sex language on fish that are born hermaphrodites and can shift back and forth between egglaying and sperm-producing modes multiple times in the course of their lives.  The term “sex reversal” also implies two opposite sexes rather than one sex continuum.  It would be much more reflective of objective reality to speak in terms of shifts in reproductive modes among hermaphrodites than about sex reversals between females and males.

The term “protogynous” used to describe gobies in the article means “starting out female,” which not only implies that the fish are not really intersex by nature, but also frames shifts in reproductive mode as only occurring in one direction: from “female” to “male.”  In fact, bluebanded gobies shift just as easily from sperm-producing to egg-laying modes when entering a group with multiple sperm-producing fish.  (See here.)  The idea that every bluebanded goby “wants to be the male” is a projection of human ideologies onto fish behavior.  The majority of bluebanded gobies at any given time are living in egglaying mode because this conveys a reproductive advantage for the group.  One could just as easily say that it’s obvious that most gobies “want to be female” since that’s what most of them do, but that one of them has to make the sacrifice and “be male” for the good of the group.  That would also be projecting emotions and motivations onto the fish, of course.  In fact, bluebanded gobies are just hermaphrodite fish reproducing in the most efficient way possible by operating in egglaying mode more often than sperm-producing mode.  But the story we read is one of enforced, devalued feminization and aspirational maleness, because that affirms sexist human gender ideologies.

Entwined with these male-privileging gender ideologies is a story about dominance and submission.  As the story goes, high status fish are dominant; low status fish are submissive.  The most aggressive and dominant bluebanded goby “gets to be the male,” while the rest have lower status that accords with their more timid female nature.  This narrative is so familiar in patriarchal society that scientists seem not to notice it’s an ideology they’re imposing on nature in their research and writing. 

Here is what we do know about bluebanded goby reproduction, stripped of human gender ideologies.  In this hermaphroditic species, the greatest number of offspring are produced when most of the fish are laying eggs.  So they form mating groups or families, typically of 3-7, in which one of the gobies’ bodies shifts to sperm-producing mode, and the rest shift to egg-laying mode.  The fish that takes on the inseminating mode needs to be robust, because it must continuously mate with the rest of the fish.  When mating groups form or change, the members all swim about actively, zipping toward one another.  (Actually, this behavior is quite common, and regularly occurs between all of the bluebanded gobies, including the egglaying ones in established groups.)  What determines which goby in a new group will take on the sperm-producing role is the behavior of the other fish.  A goby being zipped at by a zippier fish will dodge out of the way.  This gets called “submission” by scientists, but could just as well be termed “peacekeeping,” and would most accurately be simply called “getting out of the way.”  By engaging in this dance of zipping about, a new group of gobies determines which of the fish is the most energetic and robust.  Often it’s a large fish, but that’s not always the case.  That fish shifts to sperm-producing mode (unless it is already in that mode), and the others shift to egg-laying mode (unless that is already the case).

Oh, and by the way, bluebanded gobies that are in sperm-producing mode don’t “fight harder” to stay in that mode because they “don’t want to be female.”  If a group of bluebanded gobies is assembled completely out of fish that are in sperm-producing mode, all but one of them shift to egglaying mode.  This takes the same amount of time as it does for one sperm-producer to emerge from a group that is assembled out of gobies that are all in egglaying mode, and leads to the same rate of fertility.  (See here.) 

So: by nature, bluebanded gobies are intersex fish that form efficient mating groups of multiple egglayers and one inseminator, and shift reproductive modes as they move from group to group.  This is an interesting part of the wide diversity of sexual arrangements in nature.  I believe that teaching people about this natural diversity would make the world a better place for intersex people, as it would make it less likely for us to be perceived as “unnatural” and “disordered.”  But instead of teaching children about sexual diversity, educational sites either completely deny that bluebanded gobies are hermaphrodites, or only mention it as a story of rare and odd sex changes from dyadic female to dyadic male.  And scientists, educated like the rest of us in this context, impose all sorts of ideologies about binary gender roles onto what they observe about the fish, perpetuating the problem of distortion.

Nature is so much more interesting than the stories we tell ourselves about it.  It’s time to stop obscuring the objective fact of sexual diversity.