Wednesday, September 7, 2011

Intersex Fertility

My daughter was not of woman born. That is a concept that has fascinated people through the ages.

My daughter's gestation was perfectly “natural,” I should point out--but I carried her, and I was never of the female sex; I am diagnosed as "true gonadal intersex.” I was assigned female at birth, and was living as such when I gave birth to her, but I never identified as a woman, and am now legally male.

A lot of myths circulate around the topic of intersex fertility, many of them perpetuated by doctors. They all relate to the current Western insistence on the ideology of sex dyadism. That ideology holds that there are two and only two sexes, and that this is required by “nature” in order to perpetuate the human species. In fact, sex is a spectrum (see here and here for more information). About one in 150 people has some intersex characteristic. However, in contemporary Western society we are hidden away, medically “corrected,” erased. And often this erasure is bound up in rhetoric about fertility.

One way in which medical textbooks frame intersex people as “tragic” is by presenting us as usually infertile. I'm not going to spend time critiquing the idea that a person must procreate to be a fully mature and valid adult, though I certainly don't believe that to be true. What I want to address from an intersex perspective is the fact that many of us are capable of reproducing. In fact, doctors often take surgical steps to “normalize” our bodies that render us infertile. For example, children born with external testes but absent or very small phalli are often surgically assigned female. The removal of their testes of course renders them infertile. Doctors frame these children as being born “incapable of reproduction” because of their small or absent penises, but this is laughable. Deep penetration is not necessary for pregnancy to occur via intercourse. Size really is irrelevant to the delivery of sperm. In fact, the availability of in vitro fertilization means that intercourse itself is unnecessary. What doctors are doing is conflating having a large phallus with fertility and with male identity. It's magical thinking—but it is used by supposedly rational scientists to justify surgical castration of children with variant genitalia.

In framing intersex individuals as usually infertile, doctors present procreation by intersex people as a medical curiosity, justifying the publication of medical journal articles about a “case.” And they frame facilitating such a procreative act as a sort of “medical miracle,” in which the doctor treating the patient is the hero. Wishing to be seen in such a light, doctors wind up putting a lot of pressure on those of us whom they know to be intersex and potentially fertile to reproduce. This sort of external pressure is uncomfortable and almost coercive, as I myself experienced. I was told by doctors that my fertility would probably decline over time, that my atypical uterus would probably eventually “have to come out,” and I was regularly urged not to postpone trying to have a baby. Though I love my kid immensely, I see the pressure that was put on me to conceive as unethical. My road to parenthood was painful, involving a series of miscarriages, a difficult pregnancy, and a labor, with my atypical uterus, that lasted 53 hours and left me with injuries that took several years to fully heal.

In facilitating an intersex conception or gestation, doctors frame themselves as heroic in two ways. First, they are heros for making this new life possible (as if they were the ones doing the procreating). Doctors present themselves in this way in all sorts of infertility treatments, not just in the case of intersex patients. But the second heroic framing is unique: the prior doctors who chose a dyadic sex for the intersex person are presented as having done a brilliant thing. Doctors treat a successful fertilization as validating the intersex person's sex assignment. If an intersex person assigned female becomes pregnant (or an intersex person assigned male successfully inseminates), then doctors presume they made the “right choice” in the sex assignment. Thus, if an intersex patient expresses unhappiness with their sex of assignment, doctors may put even more pressure on them to procreate. Unhappiness with one's assigned sex implies a critique of the medical professionals who made it, which makes many doctors uncomfortable. Rather than questioning the practice of surgical sex assignment in infancy, doctors want the critique to go away.

This pressure placed on unhappy intersex individuals to procreate in order to validate the medical sex assignment that is causing the person unhappiness is unfair—and also bizarre. It follows the pattern of medically assessing a “correct assignment” through sexual activity. If a person is assigned female, then all is well if they are able to “accept a penis” in vaginal intercourse—and if they can actually become pregnant through this, hark—the herald angels sing the savior doctors' praises. As someone who was assigned female and did eventually have a successful pregnancy, I can tell you that this assumption did not work for me. For me, as for many, what mattered most in my sex assignment is gender identity. I did not identify as female, and thus I was uncomfortable in my assigned sex. Experiencing a pregnancy did not relieve my discomfort. Carrying a child did not “cure” my gender dysphoria with my assigned sex. It didn't make me “feel like a real woman.” It just made me feel pregnant.

I'm glad that I was able to become a parent, but believing that this should have “cured” me of my distress with my assignment is magical thinking along the lines of believing that procreating will “cure” a lesbian or gay man and make them heterosexual. Gender identity, sexual orientation, and procreative status are independent characteristics. Lesbians and trans men and intersex individuals aren't mystically “converted” by pregnancies. Gay men and trans women and intersex individuals who inseminate someone aren't thereby made straight or cis or dyadically-male-sexed.

Sometimes intersex people assigned to the female sex inseminate a partner, or male-assigned intersex people become pregnant. In the first half of the 20th century, when intersex children were rarely if ever surgically sex assigned, and doctors wrote about “cases of hermaphroditism” they encountered as adults, this was a popular topic in medical journal articles, but such is not the case today. Since there is no reason why intersex people should be born with less capacity for fertility that in the past, there are two possible explanations. Either medical interventions are rendering more intersex individuals infertile, or doctors have no incentive to publish about what they would deem “sex assignment failure.” A person a doctor has assigned female is not “supposed” to impregnate anyone, thereby supposedly providing embarrassing proof they should have been assigned male. The idea that someone might actually be happy with a female sex assignment and also pleased to be able to contribute to the conception of a child by providing sperm in the way their body permits does not enter the picture at all. The dyadic gender ideology doctors impose awkwardly onto intersex people is again revealed.

I believe that the framing of sex as dyadic also contributes to the everpresent popular question about fertility and “hermaphrodites”: can we impregnate ourselves? The answer is that it is extraordinarily unlikely, but I believe the reason this tired old query nevertheless comes up again and again is due to how people, having no idea at all of what intersex bodies are actually like, have to use their imaginations. Given the dyadic sex ideology, they figure that if a “hermphrodite” is both male and female, they must have both sets of “organs,” meaning a penis and vagina and testes and uterus and ovaries. Truly, if you ever want to despair of the level of ignorance about intersex bodies, just do an internet search for “hermaphrodite impregnate”. . . I find it hard to decide whether to laugh or cry reading people's musings on this topic.

But I can't really blame people on the street for the depth of their ignorance. People don't know about intersex bodies and experiences because we are hidden from them. Our sex status is erased by the legal requirement that we be declared male or female at birth. Our bodies are redacted by doctors trying to remove the evidence of our physical “deviance.” Information about intersex statuses is not taught in high school biology classes. The fact that sex variation is so common is a fact kept, for some reason, secret. And the large majority of intersex people are well-schooled to keep our “disorders” in the closet.

So I'm less bothered by the tediously-repeated “if you're a hermaphrodite, could you get yourself pregnant” question than I am by magical thinking on the part of medical practitioners. Intersex people are not tragic figures due to infertility. Some of us don't want children, and some of us adopt. Some of us do indeed produce children ourselves. We've done this throughout all of human history, not just recently due to medical miracles. Many of us who do reap the rewards of fertility do this in private, with no medical journal articles trumpeting a star in the east. In fact, some medical “corrections” of our physical differences render us infertile, and I don't see why that's treated as unimportant when doctors are so very willing to write articles about their “cases” who do prove fertile. And the magical thinking behind the idea that doctors can validate a sex assignment through the intersex person contributing the “correct” component, egg or sperm, to a conception just boggles my mind.
It's time for some more sophisticated thinking about intersex fertility.