Trans and Intersex Children: Forced Sex Changes, Chemical Castration, and Self-Determination

Children’s lives lie at the center of social struggles over trans gender and intersex issues. If you talk with trans and intersex adults about the pain they’ve faced, the same issue comes up over and over again, from mirror-image perspectives: that of medical interventions into the sexed body of the child. Intersex and trans adults are often despairing over not having had a say as children over what their sexes should be, and how doctors should intervene. Meanwhile, transphobes and the mainstream backers of intersex “corrective” surgery also focus on medical intervention into children’s bodies. They frame interventions into the sexual characteristics of intersex children as heroic and interventions into the bodies of trans children as horrific.

The terms and claims that get tossed around in these debates are very dramatic. Mutilation. Suicide. Chemical castration. Forced sex changes.

We need to understand what’s going on here, because it’s the central ethical issue around which debates about intersex and trans bodies swirl. The issue here is the question of self-determination, of autonomy. Bodily autonomy is the shared rallying cry of trans and intersex activists, though we might employ it in opposite ways. Refusing it to us is framed as somehow in our best interests by our opponents.

In this post we will look at how four groups frame the issue: intersex people, trans people, the mainstream medical professionals who treat intersex people, and opponents of trans rights.

If you talk to people who were visibly sexvariant at birth, you hear a lot of pain and anger and regret about how their bodies were altered. This is crystallized in the phrase of intersex genital mutilation, or IGM. As a result of infant genital surgery, many intersex people suffer from absent or reduced sexual sensation—something mainstream Western medicine presents as unethical female genital mutilation (FGM) when similar surgeries are performed on girls in other societies. There are further sources of pain: as a result of “corrective” surgeries, intersex people can suffer a wide range of unhappy results, such as loss of potential fertility, lifelong problems with bladder infections, and/or growing up not to identify with the binary sex to which they were assigned. It is extremely painful to identify as female and to know one was born with a vagina that doctors removed with your parents’ consent, or to identify as male and to know one’s penis was amputated. Imagine if someone performed a forced change on you--would you not feel profoundly violated?

So the intersex perspective is that no one should medically intervene in a person’s body without that person’s full informed consent. Bodily autonomy is a fundamental right. Nobody except you can know how you will feel about your bodily form, whether you might want it medically altered, what risks of side-effects you’d consider acceptable. Routine “corrective” surgery performed on intersex infants is thus a great moral wrong.

When you speak with trans people, childhood medical intervention again comes up with an air of great regret, but now the regret is that one was not permitted to access it. Almost every person I’ve ever spoken with who wants to gender transition medically, whether they’re 18 or 75, has expressed the same fear to me: “I’m afraid I’m too old!” For a while this mystified me (how is 22 “old”?), until I realized what they meant was, “I’m post-pubertal.” For many trans people, childhood was awkward but tolerable, as children’s bodies are quite androgynous. Puberty, however, was an appalling experience. Secondary sexual characteristics distorted the body—humiliating breasts or facial hair sprouting, hips or shoulders broadening in ways no later hormone treatments could ever undo. Many trans people live with lifelong despair over how so much maltreatment and dysphoria could have been avoided if they could just have been permitted to avoid that undesired puberty.

So for trans activists, advocating for trans children so that they might avoid this tragedy is vitally important. The child’s autonomy is central, as it is for intersex advocates, but here the issue is getting access to medical treatment in the form of hormone suppressants, rather than fighting medical intervention. What trans activists seek is the right of children to ask for puberty-postponing drugs, to give the children’s families and therapists time to confirm that the children truly identify as trans, and fully understand what a medical transition involves. Then the individual can medically transition to have a body that looks much more similar to that of a cis person than can someone who has developed an unwanted set of secondary sex characteristics.

So for trans and intersex people, children’s autonomy is paramount when it comes to medical interventions into the sexed body. No child should have their sex (e.g. genitals, hormones, reproductive organs) medically altered until they are old enough to fully understand what is involved and actively ask for such intervention. Conversely, once a child is old enough to fully understand what is involved in medical interventions into the sexed body, and requests such intervention, then it should be performed—whether the child is born intersex or not.

This is not yet mainstream medical practice, however. Today, one in every 150 infants faces medical intervention into the sexed body to which they cannot object or consent. Doctors routinely perform such “corrective procedures” on babies with genital “defects” and “malformations.” Meanwhile, few trans-identified children are supported in their identities by families and medical practitioners—and great controversy and resistance swirls around them when it does happen.

So let’s look at the arguments made by mainstream medicine and transphobic activists. How do they counter the cry for autonomy, given that self-determination and freedom are such central ideals in Western societies? What we’ll see is that they employ two opposing claims based in medical ethics: the duty to save a life, and the duty to first do no harm. If we want to protect the rights of trans and intersex children, we have to understand these arguments and be able to counter them.

When intersex advocates try to fight the framing of intersex children’s bodies as “defective” and somehow in need of surgical “correction,” mainstream medicine responds with a claim of medical necessity. In some very rare cases, particular intersex conditions can be associated with actual functional problems such as an imperforate anus, clearly a serious medical problem that necessitates surgery. But the vast majority of medical interventions into intersexed bodies take place without any such functional, physical problem exsting. They are responses to a social issue (discomfort with sex variance) rather than a physical one. What doctors do, however, is reframe social issues into medical ones. “If we don’t do this surgery, this child will be mocked and humiliated—“he” won’t be able to stand to pee, “she” won’t be able to have “normal sex,” “it” will never be able to marry. The child will be a social pariah and thus be at risk for suicide.”

Through this line of argument, altering the body of the sexvariant infant is cast as a noble act that doctors perform out of their duty to save lives. To counter this, what we need to do is point out that actual studies of intersex adults show that while we do have a heightened risk of depression and suicide, these are caused by unhappiness with our medical treatment rather than prevented by it. Loss of sexual sensation, feelings of having been humiliated by doctors, pain from years of “repair” surgery after “repair” surgery, and for those who do not identify with the binary sex to which we were assigned, the vast sense of betrayal that those who were supposed to care for us subjected us to a forced sex change—these are what lead to an increased risk of suicide. What would really help is would be for doctors to follow the precept of “first do no harm,” to perform no procedures upon us without our full informed consent, and meanwhile, to provide intersex children and their families with social support.

Invocations of “primum non nocere,” first do no harm, and of despicable medical impositions on the lives of innocents are also raised by anti-trans advocates. Transphobic activists generally frame all medical transition interventions as mutilations, and this rhetoric rises to fever pitch when the issue of trans children arises. Recently, anti-trans rhetoric has framed the medical provision of puberty-postponing drugs as “chemical castration” (e.g. in this blog post).

“Chemical castration” is an odd concept. First off, if you read any medical article on the topic, you will find it starting by pointing out that the term is a misnomer, as none of the medications used in “chemical castration” destroy the gonads. The term is nevertheless employed due its specific history as a treatment being given by court order to “sexual deviants” to suppress their ability to have sex, where some prior courts had employed actual surgical castration. Today, some jurisdictions use “chemical castration” in cases of pedophilia, but it the past it was a treatment imposed on men convicted of sodomy—that is, to gay men in an era in which gay male sex was criminalized. Transphobic activists use the term “chemical castration” to evoke an aura of adult sexual deviance, in a manner calculated to frame doctors who provide puberty-suppressant drugs as sexually abusing children.

There is a curious twist in this matter of “chemical castration,” in that universally when court-ordered in the past, and often still today, it did not consist of testosterone suppression drugs as you would expect. Instead, injections of estrogen and/or progesterone were (and are) given. In essence, it caused a forced sex change. Thus, for example, when codebreaking British war hero Alan Turing was convicted of homosexuality in 1952 and sentenced to “chemical castration,” he found the unwanted sex changes in his body so horrifying and humiliating that he committed suicide two years into “treatment.”

In the case of trans-identified kids today, the use of the term “chemical castration” is thus a double misnomer. Firstly, no child is castrated—instead, puberty is simply postponed so that if the child, family, and therapist all agree later that a medical transition is appropriate, unwanted secondary sexual characteristics will not have developed. Plenty of adolescents are “late bloomers” by nature; in fact, puberty today occurs many years earlier than it did through most of human history, when human diets lacked sufficient fats and nutrients to support early puberties. So postponing puberty carries no significant dangers. Further, the point of hormone suppression is not to cause a sex change, in contrast to court-ordered “chemical castration treatments.” The point is merely to buy time to ensure that the trans child in question fully understands zir gender identity and the implications of medical transition.

So: we’ve seen a lot of charged language, of claims and counterclaims regarding mutilation versus vital treatment, cruel withholding of medical assistance versus the imposition of sex changes on unconsenting children. How should trans and intersex advocates respond?

What I would do is to point out that strange and conflicting ideas about children’s autonomy and free will are presented by our opponents. When specialists in intersex “corrective” treatments speak to parents or write in medical journals, they urge that genital surgery be performed in infancy, before age two and a half if at all possible. They claim that this way the child will not remember the treatment and will thus adjust well to the altered genitals and/or sex status. (As if medical monitoring and intervention did not often extend throughout the child’s life, and the procedures left no scars and caused no loss of sensation, so the child would “never notice.”) The age of two and a half came out of now largely-discredited ideas of a milestone of “gender constancy” occurring then, based upon notions of the developing brain that directly relate to autonomy. Before age 2.5, it was basically argued, the baby is irrational and lacks agency, and thus thinks magically about bodily sex, including accepting the “crazy” idea that the sex of the body can change. So, in urging very early intervention into intersex bodies today, conventional medicine is urging the total avoidance of the child’s rational thought and agency.

When it comes to treating trans children, on the other hand, instead of rushing things, all sorts of actors want to draw them out. Most doctors and clinics only provide transition services to legal adults. Those few who treat trans children are extremely cautious about providing any medical interventions other than the postponing of puberty.

Both of these approaches deny children autonomy over their bodies and their lives.

What we must urge is that society consistently respect the rights of children. No children should ever be subjected to sexual surgery without their consent. No children should be forced to have cosmetic surgery. But as children mature, they become able to consent to medical treatment that they do actively desire.

How old is “old enough” to agree to medical interventions into the sexed body? That answer depends on the given child—but 2.5 is certainly too young, and 18 is in most cases too old. What I suggest is that when addressing a medical practitioner urging genital surgery on an intersex infant, that we ask, “Would you perform a sex change on a child of this age who was not intersex?” Conversely, when facing transphobic activists saying that no one who is not a legal adult can be old enough to consent to medical transition services, we should ask if our opponent would say the same if the child were intersex. For example, a child with congenital adrenal hyperplasia may be born with a penis externally, and a uterus and ovaries internally. At around age 12 or 13, if there has been no medical intervention, that child can begin to menstruate through the penis, develop breasts, etc. Would the opponent argue that the child could not be old enough to say that he identifies as male and wants to take testosterone (or that she identifies as female and has decided that she wishes to have surgery to feminize her genitalia)? Would the opponent argue an intersex pubescent child should not at least be able to take puberty-postponing medications to avoid unwanted penile menstruation if they and their family and support professionals were still unsure whether to commit to any more permanent intervention?

What we must ask is that society treat intersex and trans-identified children consistently. We all raise our children to learn to make good decisions, so that they can lead good lives. We must nurture children’s autonomy as they grow, understanding that there are some decisions only they can make for themselves. To force a person to live in a sex with which they do not identify is cruelty; to impose unwanted bodily alterations unconscionable. Wishing happiness for our children, we must nurture and then defer to their right to self-determination over interventions into the sexed body.

Deaf Children, Intersex Children, and DSDs

I want to explain a division in our community, between intersex advocates and partisans of the terminology of "DSDs."

Every day, intersex children are born to parents who are shocked, lost at sea. "How can this be happening," they cry, "I've never even heard of such a thing." And this, this is the crux of the problem. It's this problem of being born as strange little changelings to our parents that perpetuates infant sex assignment surgery, despite the ever-mounting evidence that the results are frequently unsatisfactory. And it is the issue of how to approach infant sex assignment that lies behind our division into two warring camps: those who say the term "intersex" is overpolitical and imprecise and that the "proper" term is "Disorders of Sex Development," and those of us who say we are not disordered, and take pride in calling ourselves intersex people.

The intersex and DSD camps are constantly battling now, at least in the U.S. The thing is, this is not unique to our community. It is something we share with others. Similar controversies erupt around Deaf children born to hearing parents, for example, or, in some cases, children of color adopted by white parents. This commonality is very instructive--controversy arises when children of marginalized status are born or reared by parents who are privileged along that axis of identity.

Consider the organized Deaf community, which centers around institutions and locales where signing, ASL, is the norm. This Deaf community experiences itself as a linguistic minority, rather than "disabled." Members of such Deaf communities are not impaired in their daily lives. Able to communicate in their rich language with those around them, they are enabled to study and grow, and develop a strong culture, literature, and traditions.

The problem is that children who cannot hear are born to hearing parents all the time. And those parents are shocked, at sea. Some hearing parents don't want to give up on the future they had imagined for their children, and say, "I just want my child to be normal!" And "normal" for them means having their child live and go to school in a "mainstream" hearing context, and focus on learning to speak. It means getting cochlear implants and focusing everything on trying to make sense of a bit of sound. It means that these deaf children spend their days isolated, surrounded by people who can't understand them, and spending countless hours both in school and out trying to learn how to speak words they cannot hear, instead of quickly and easily learning a visual language they have the sensorium to perceive, and spending their hours at school learning math and history.

The signing Deaf community aches for these isolated children. They see the children as disabled by their parents, failed by the professionals who surround them, misunderstood by doctors. And the Deaf community pleads: please, parents, accept that your child cannot hear. Make them part of the Deaf community by allowing them to learn Sign from infancy; become part of the community yourself by learning Sign. Some parents take the message to heart and find their lives much enriched; others resist--but at least the message is out there, and Deaf children become aware of it soon enough. You can see a person born without hearing as defective, disabled, in need of medical alteration. Or you can see them as simply different, Deaf, members of a rich minority culture.

The split between the medicalized and cultural approaches to Deafness are parallel to the split between the advocates of DSD terminology and intersex activists, but the context is different, because there are no organized intersex institutions, no consolidated intersex neighborhoods. We have no Gallaudet (the excellent Deaf university in D.C.). The situation for intersex children is more like. . . well, imagine if all Deaf children were given forced cochlear implants and their families told to hide the equipment, never to let anyone know their children couldn't hear, and to avoid even acknowledging to the children themselves the issue of their not hearing. The parallel's not exact--it's harder to conceal sensory impairment--but it does give a sense of where we stand.

Most intersex/DSD advocates of any stripe share something in common: we want infant sex assignment surgery to be curtailed. We want intersex children to be allowed to retain their sexual sensation, any chance at fertility, and the right to have the gender identity that they develop be respected and recognized. Let the babies grow up, we plead, and decide what surgery, if any, they want. But the intersex advocacy community is small and diffuse, as compared to the Deaf community, and so far, we haven't gained much traction. Parents of intersex babies have never heard of us, and doctors dismiss us as a few disgruntled outliers. So every day in the U.S., babies continue to receive sex assignment surgery. Most of us continue to be raised in shame and utter secrecy, our genitals never looking "normal" after surgery anyway, but insensate, in pain, and often being reared as a sex we don't feel is ours.

The situation is bad, and something needs to be done about it. And this is where the small pool of intersex advocates splits. Who should we turn to for help? How can we improve the lives of intersex people? Will professionals save us? Or do we save ourselves, through community building and selfadvocacy?

Those of us who identify as intersex activists, in those terms, follow the route familiar to all civil rights' movements (and a fair number of us have been involved in LGBT politics). The basic model for improving marginalized lives, in the civil rights vein, is to take pride in one's identity, however stigmatized by the majority, and then to take action to get the majority to treat one's community better. The route to social change is rooted in embracing selfhood, and then moves on to a familiar array of tactics: be visible; protest; write letters to the editor, one's senator, one's pastor or rabbi; seek protective legislation, etc. etc..

So we act up. And one of the things we do is let people know we are very dissatisfied with how we have been treated by doctors. Unsurpisingly, many doctors have not appreciated this. It's damaging to one's selfimage, to listen seriously to a person who says, "You were not my savior or my hero--you hurt me, you did me wrong." Far easier for a doctor to dismiss our small if vocal group as a radical fringe, or perhaps to see us pityingly as the victims of older forms of surgery, very unlike the babies they now save from freakish lives with their newer, shinier surgeries.

And here's where advocates of DSD terminology chime in. They say, "We simply cannot afford to alienate the doctors, because it's the doctors' actions that make or break us. We need them to stop performing unnecessary surgery on babies' genitalia. And the only way to do that is to convince doctors that we are sane and not crazy. We need to be respectful to them, so that they will listen to us, and we can appeal to their desire to improve treatment." And so the advocates of "people with DSDs" are the political advocates of depoliticization. They argue, "Intersex activists are too far out there. Doctors see red when they hear the term 'intersex' now. Parents, too. Parents don't want to hear that their kid is some other sex, like permanently. In fact, lots of people in our own community are uncomfortable with the term. They don't want to be part of some group lumped together with queer activists, they just want to be seen as people."

I don't want to be seen as oversimplifying the DSD advocacy position--there are more nuances to it. You can read an eloquent defense of the terminology that is respectful to intersex-identified people here. But basically, the position is one of not rocking the boat. We should look to professionals, to doctors, to save us. If we're rational and polite and deferential and apolitical in our presenting of our case to doctors, then in time they will change the treatment regimens, and parents will listen to the medical professionals.

The thing is, similar lines of argument have been raised in the past. I recall in the 1980s, when many quiet, marginalized gay-identified people, living without protection from any nondiscrimination policies, looked to professionals to save them. Political activism, they argued, just alienated the populace. They looked to scientists to save them by finding the "gay gene." But it has been the brave actions of masses of LGBT people coming out at home and work and being politically active that have led to the gains in protection for LGBT people and same-sex couples, not some scientific discovery.

Or consider Dr. Martin Luther King, Jr.'s famous 1963 "Letter From a Birmingham Jail," an impassioned defense of nonviolently confrontational civil rights activism. The letter was addressed to a collection of moderate clergymen who had appealed to King to stop pushing sit-ins and to wait patiently for the legislature to produce civil rights protections. In due time, these clergy argued, if you are polite and trusting, these professionals will act. Just stop agitating, stop alienating them, be patient. But King was right--it was continuing civil rights activism that led to the enactment of the Civil Rights Act of 1964. I believe the lessons of our history are clear: if you want your people to be treated better, then take pride in who you are and demand your rights. And that is what I intend to do.

It's for this reason that I do not identify with the term "DSD." I am not disordered. I was born as nature intended me, and I feel no shame in that. I am an intersex person, and I personally have no interest in having my genitalia surgically altered. I shall not sit meekly by and wait for professionals to quietly change their minds about how to treat the young members of my community. I am going to be noisy and public in my demands, and I am going to work with our nascent social movement. My goal is to make the public aware that we are here, and that infant sex assignment surgery is making things worse rather than better for so many of us. It's public pressure and a shift in public opinion that will finally end the era of attempting to erase us medically. We will be recognized, respected, and no changes to our genitalia will be made unless and until we reach an age where we can request them, uncoerced.

In the future, I hope, when intersex babies are born, their parents, though probably still feeling shocked intially, will know that we are out here, leading happy lives. They can embrace their children--see them as members of a minority, yes, but also as lovely, not defective. They can learn from their children, about privilege and marginalization, to be sure, but also about the vibrance of human diversity. And these children will be able to connect with our community, help build our culture as a people, and contribute to the enrichment of our nation's web of identities, as today's Deaf community does.