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.