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.

Intersex Genitalia Illustrated and Explained

There is a lot of variation in how the genitalia develop from person to person in all of us. Nature provides us with a wide spectrum of forms, onto which our society imposes two absolute categories of male and female. In my last post, I described how all people start out with the same genitals in the womb, and how the phalloclitoris differentiates during development. In this post I will discuss the range of natural genital forms, explaining how they develop from the shared embryonic phalloclitoral structures.

I will illustrate this post with simple diagrams. I know that there is a lot of interest in what intersex genitals actually look like—most of the people who find this blog do so by searching for these words. I've discussed elsewhere why I will not post medical photographs of intersex people's genitalia—these often picture children photographed without their consent, and I will not participate in their exploitation. But I do support people's impulse to know more about the range of human forms. I want to help lift the veil of medically-enforced secrecy that makes our bodies invisible, so that interesex bodies can be demystified and accepted. So: diagrams it is.

I will start by reviewing the structures of our shared original genital form, and showing how they develop in what are deemed “normal” males and females.

The Embryo

We all begin life with genitals that have four basic external elements. At the top is the part numbered 1 and colored pink on this illustration: the sensitive end of the phalloclitoris, which can differentiate into the head of the penis or clitoris. Below it is structure 2, drawn in orange, which is capable of differentiation into either a phallic shaft, or clitoral body and labia minora. In the center is structure 3, drawn in green: an inset membrane that can widen or can seal as the fetus develops. It will form the urethra, and the vagina, if any. And at the outside is the fourth part, colored blue: the labioscrotal swellings, which can develop into labia majora or a scrotum.

“Normal Differentiation”

You can see how the four sectors of the embryonic genitalia differentiate in the diagrams of “typical” male and female genitals pictured here (illustrated without the foreskin or "hood"). Click on any illustration to see it larger. Notice that the pink phalloclitoral head points downward in typical female development and upright in typical male development. The orange body of the phalloclitoris separates and is buried beneath the labia in females, while it closes around the urethra and forms the penile shaft in males.

Sex variance occurs in many forms, but they are not random. Intersex conditions are produced by regular patterns of variation in development of one or more of the four parts of the embryonic genitalia. Let us consider a series of intersex conditions to see how these variations arise, and how they are framed by doctors.

“Aphallia”

Aphallia the term given by doctors to a form of sex variance produced when the first two sections of the embryonic genitala do not develop. While this is equally likely to occur in individuals with ovaries as those with testes, it is only generally commented upon medically when the individual has testicles and XY chromosomes. This illustrates how Western medicine is permeated by a strong gender bias. Having a large, erectile penis is considered a necessity for males, and its absence a tragedy of the highest order, to be addressed by somber medical articles. Having a clitoris capable of sensation and erection, however, is given little attention—so little that its congenital absence is treated as worthy of nothing more than a footnote.

The gendered beliefs that permeate Western medicine are further illustrated by the treatment plan for infants with testes who have aphallia. American doctors typically give these children sex reassignment surgery to remove the testes and create a vagina, it being apparently impossible to tolerate the idea of children being raised as boys without a penis. Without this surgical castration, the children could grow up to be fertile, but their fertility is medically sacrificed without their consent. What is particularly noteworthy is that doctors speak of the sex-reassigned patient with aphallia as growing up to have “normal female sexual function.” “Normal,” for a female, is thus medically defined as being capable of receiving a penis in a vagina, not having sexual pleasure.

“Microphallus”

Some people have large feet and some people have small ones; some have large noses and while others' are petite. When the phalloclitoris is quite small in a person with external testes and a male genital configuration, doctors say the individual has “microphallus.” If the testes are deemed "inadequate," doctors often advise sex assignment to female in infancy as they do in the case of aphallia, because life as a man with tiny sex organs is deemed tragic. Again, the individual's fertility is sacrificed without consent. If the testes are considered normal the child may be treated instead with injections of testosterone, in effect triggering puberty in toddlerhood and leading to moderate enlargement of the clitorophallus (along with other premature pubertal effects such as the development of adult patterns of body hair).

Rarely considered as options by doctors are simply allowing the child to live life as a male with a small penis, or to decide for zirself what course of action to take. Whether the sacrifice of some or all sexual sensation to have genitals that appear female is better than living life as a person with testes and a very small phallus is not a question that science can give a single “correct answer.” It is a subjective and highly personal decision, and will be driven most strongly by the gender identity the child grows to develop. I and other intersex advocates believe that only the intersex person can make such a lifechanging decision, and that for doctors to force their choice upon an unconsenting child is both arrogant and cruel.

“Clitoromegaly”

When a child with typically-male-configured genitals has a large phalloclitoris, the doctors make admiring jokes with the parents. But when the child is female, having a large phalloclitoris is deemed a “birth defect.” Despite the lack of any functional harm from having a large clitoris, doctors perform surgery to “reduce” it to the “acceptable” female range. This often seriously impairs sexual sensation. Although today doctors like to brag that they preserve sexual sensation because they have abandoned the older surgical treatment of “clitoral amputation,” usually some sensation is lost in “clitoral reduction,” and sometimes the phalloclitoris loses all sensation, even though some of the tissue is permitted to remain. It is especially ironic that the removal of part of the clitoris in traditional female circumcision practices is renounced as “female genital mutilation” by Western doctors, yet they perform a similar procedure in cases of “clitoromegaly” without compunction.

“Chordee”

The head of the phalloclitoris bends down in typical “female” configuration. When it does so in a person assigned male, it is termed “simple chordee.” In some individuals, the only atypical characteristic is the folded-down head of the phallus, which is of typical penile size. Doctors present this status as a “malformation of unknown cause,” rather than as a typically-female shape of the phalloclitoris in a male, because they are averse to terming any condition in a child assigned male “intersex.” But chordee is not a random alternative shaping of the penis, as if the penile head might have been equally likely to spontaneously bend in an S-shape. Chordee arises when Sector 1 of the embryonic tissue develops in the “female” configuration, while the rest of the genital development is typically male. Doctors usually suggest surgical “correction” of the phalloclitoral bend, citing locker-room teasing and a purported challenge to fertility. Such surgery presents a serious risk to sexual sensation in the penile head. Furthermore, fertility is not impaired by having a bent or curved penis—the production of sperm is unaltered. Penetrating some partners may be more difficult, but there are many ways to engage in both sexual interaction and fertilization other than via penetrative sex, and only the possessor of the bent penis can decide whether it makes sense to risk the sacrifice of sensation in the phalloclitoral head to make it easier to engage in penetrative sex with partners who prefer a narrow penis. (Some partners may find the phallus with chordee to be more sexually stimulating than a typical penis.)

In other individuals with chordee, the phalloclitoris is of intermediate size. It appears as an intermediary form evenly balanced between the male and female manifestations of the phalloclitoris. Often the individual also has a shallow vagina (discussed below under “hypospadias”).

Whether individuals assigned female at birth may have phalloclitoral heads that do not bend down like a typical clitoris but conform instead to the linear shape typical of males is not discussed in Western medical literature, with its obsession with penises and general disinterest in clitori. I consider it extremely likely that this unnamed counterpart to chordee does occur.

“Diphallia”

Section 2 of the embryonic genitalia is generally expected to fuse into a single penile shaft in male development, or to spread apart to form the two clitoral crura around the labia majora in female development. If the genitals devleop along male lines but the two sides do not fuse, the individual is born with two separate phalloclitori, side by side, each associated with one testis and having only one corpus cavernosum. Doctors remove one of the phalli (the one deemed smaller, no surprise there), though as in clitoromegaly there seems to be no functional danger involved in having two clitorophalli. This gential configuration can be associated with actual functional problems like an imperforate anus, obviously a true surgical emergency, but constructing an anus has nothing to do with removing half of the phalloclitoris. Doctors do not deem diphallia an intersex condition—the off-the-cuff reading is that the child is “doubly male”--but in fact the clitorophallus has developed in a manner intermediate between male and female norms.

A rarer bodily form than diphallia is phalloclitoral duplication, in which the embryo begins to twin in the genital region but ceases there—similar to what happens in the case of conjoined twins or people born with three legs. The individual is born with two penises or clitori, which may be located side-by-side or one above the other.

“Hypospadias”

Physical statuses in which a child develops external testes while Sections 2 and 3 of the phalloclitoris develop atypically are grouped together under the medical term “hypospadias.” Segment 3 of the embryonic genitalia forms the urethra and vagina, if any. In the normative male configuration, there is a urethral opening at the tip of phalloclitoris, and no vaginal opening. In individuals with hypospadias, the urethral opening is closer to the typically female location, and there may be some vaginal tissue. Individuals born with hypospadias in the U.S. today are almost always assigned male, and doctors rarely call them intersex. This is an ideological choice rather than one driven by anatomical logic. The medical belief seems to be that if a child has external testes and the clitorophallus can be surgically reconstructed along penile lines, then the child should be assigned male and no question ever raised in the parents' minds about the child having an intersex status. Doctors believe being seen as less than “fully male” is untenable for a man.

The degree of difference between typical male morphology and the genital arrangement of individuals with hypospadias varies widely. In many, it is simply a displacement of the urinary meatus from the very tip of the penis, as shown in the first illustration above, so that the urinary orifice is located lower on the phallic head, which is of ordinary penile size. Doctors “correct” this in childhood, claiming that having a “displaced” urinary meatus is unacceptable, as it will lead to teasing, and ostensibly problems with urinating in a standing position and fertility. Loss of sensation in the head of the penis, fistulas, and problems with recurrent bladder infections are deemed a better outcome by doctors than perhaps needing to sit down to pee—though in adulthood, many who have had this surgery complain that the side effects outweigh any benefits in their lives. The idea that fertility is impaired by having semen emitted from a position slightly lower down on the penis is laughable.

Hypospadias is measured by doctors in degrees. The greater the degree, the more the phalloclitoris assumes a vaginal configuration. The urinary outlet takes the shape of a small vaginal slit if located further from the head of the phalloclitoris, becoming larger if located further down the shaft, as in the second illustration above. If the urethral opening is located at the base of the phalloclitoris, the condition is termed “perineal hypospadias.” In people born with this configuration, the genitalia appear intermediate between the female norm and the male, with a vagina located in front of or between the labioscrota. Testes are located in the labioscrotum, with surface skin that can appear more close to typical labia majora or to scrotal skin. The clitorophallus is often intermediate in size and the head may bend down in the typical clitoral configuration called chordee. While children with “perineal hypospadias with chordee” have genitalia that look closer to the female norm than the male, they still may not be classified as “officially” intersex by American doctors, and surgery that closes their vaginas, dissects the clitorophallus from the perineum, and repositions the urethra to the head of the clitorophallus is termed a “repair” rather than sex assignment surgery. Such extensive surgery is painful, life-altering, and usually leads to loss of sensation. Furthermore, a substantial number of people born with this intermediate configuration grow up to identify as female, despite their infant surgical sex assignment to male, and bitterly resent having been given surgery that removed their vaginal tissue while forming their phalloclitori into the sensation-impaired semblance of a penis.

Rarely mentioned by doctors in articles discussing hypospadias is that it can be accompanied by intermediate internal sex structures, particularly a large “prostatic utricle”. (The embryonic structure that typically develops into a uterus in more female bodies forms a small “utricle” in the center of the prostate in bodies that are typically male.) In intersex bodies, this may exist as a small or average sized uterine structure within or aside a prostate—the greater the degree of the hypospadias, the more likely there is a utricle, and the larger it is likely to be. It fascinates me that the fact that people with hypospadias often have a uterine structure, evident in any literature search on the prostatic utricle, is rarely mentioned in medical descriptions of hypospadias, while much rarer associations between intersex conditions and cancer are often mentioned in articles on other intersex conditions. I believe it is not mentioned because discussing a uterine structure would undermine the medical framing of children with hypospadias as “boys with a penile malformation” rather than as intersex children.

"Vaginal Agenesis"

In some individuals, external genitalia are formed which appear close to the female side of the spectrum, but Section 3 only creates a shallow vagina or smooth patch of lubricating skin. Internally, such children may have no gonads, or may have ovaries but no uterus, or may have ovaries and an atypical uterus. Individuals with vaginal agenesis are always called female rather than intersex by doctors, even when they have no gonads and will develop no secondary sexual characteristics (such as breasts or facial hair absence/presence) without taking hormone medications. Again, Western medical ideology seeks to define away intersexuality as much as possible.

There is a lot of attention given by doctors to the creation of a vagina for children with genitals that otherwise appear female to them. This is framed as necessary for “sexual functioning,” presuming that forms of sexual activity other than penetration of a vagina by a penis are “not really sex.” As is the case with many intersex bodies, surgeries are often performed which sacrifice the capacity for sexual sensation out of an ideology that this is necessary for “normal sex.”

“Female Pseudohermaphroditism”/ Congenital Adrenal Hyperplasia

In some intersex conditions, the four zones of the external genitalia develop so that they look typically male (with urethral opening at the tip of the penis, scrotum, and no vaginal opening) but the individual possesses a uterus and ovaries, and the scrotum is empty. The most common diagnosis in people with such a bodily form is congenital adrenal hyperplasia or CAH in XX individuals. While most any person on the street would say that having both a penis and a uterus is an intersex bodily form, doctors hem and haw, and say instead that the child, while intersex, is a “pseudohermaphrodite,” somehow really female. This is based on the move by doctors almost a century ago to define intersexuality out of existence by saying that only individuals with the very rare condition of having one ovary and one testis, or having intermediate ovotestes, are “true hermpahrodites.” An intersex person with testes was deemed “really male” and anyone with ovaries “really female” by the creation of the term “pseudohermaphrodite.”

At the time doctors came up with the idea of the “pseudohermaphrodite,” sex assignment surgery had not yet been developed. Today, however, doctors insist that babies with CAH should be surgically assigned female in infancy. The language of “female pseudohermphroditism” is used to sooth parents who are shocked at the idea of a doctor cutting off their baby's penis. Doctors tell them that it is not “really” a penis, but is “really a clitoris” that is malformed. The fact, of course, is that all babies have phalloclitori—and that their baby's is exactly like any other typical boy's penis. If doctors were consistent, they'd have to call all men's phalli “malformed clitori.”

In any case, doctors in the U.S. routinely perform what they term “clitoral reduction” on children with CAH—that is, removal of almost all of the phallus--and cut apart the scrotum to give it the form of labia majora. In pressing this surgical sex assignment plan, doctors present parents with an odd assessment of the risks and benefits of such a course of intervention. They gloss over the fact that cutting off most of the phallus seriously impacts adult sexual sensation. They tell parents that this must be done to avoid the catastrophe of adult menstruation through the phallus. (Note that they do not inform parents of children with perineal hypospadias that menstruation is a “danger,” or suggest that children with hypospadias be assigned female to avoid penile menstruation.) Doctors do not inform parents that an alternative would be hormone treatment to suppress menstruation, or that their children could grow up to identify as men and function sexually as males, albeit without semen production. (Some ejaculation could be possible, but it would not contain sperm.) Rather than warn parents that many children with CAH grow up not to identify as female and to despair over having been effectively castrated, they warn that the children “have a heightened risk of lesbianism,” which is an eye-goggling assertion that is both homophobic and ignores the issue of gender identity.

“Male Pseudohermaphroditism”/ Androgen Insensitivity Syndrome

Children with complete androgen insensitivity syndrome or CAIS are the counterparts to XX CAH children. Their external genitalia take the typical female form, but internally they lack a uterus, and in the place where one would ordinarily find ovaries, they have internal testes. Because their bodies do not respond to testosterone, they grow up to develop very feminine secondary sexual characteristics at puberty, though they will never have menstrual periods. Despite their typically-female appearance, doctors call these individuals “male pseudohermaphrodites” because they have testes. However, in contrast to the treatment of children with CAH, doctors do not go on to say that they CAIS children have “malformed penises” that must be surgically altered to fit their “true sex.” Instead of urging genital reconstruction, they tell parents to raise their CAIS children as girls, warn parents that their internal testes could possibly present a risk of cancer, and tell them to have the testes removed.

Unlike children with CAH, who often regret their sex assignment surgeries, individuals with CAIS seem to usually accept having been assigned female at birth. This is probably because of the contrast in the intersex individuals' experiences. Children with CAH are assigned female at birth via traumatic, scarring surgeries that impair sexual sensation, and then must take testosterone-suppressing drugs for life, while those with CAIS may not find out about their condition until puberty, retain uninjured and unaltered genitalia, and take no hormone-suppressant drugs. Nevertheless, despite typically identifying as female, these individuals are termed “male pseudohermaphrodites” on all of their medical records, and must live with the consequences of being deemed medically male throughout their romantic and sexual lives.

Some children have Partial Androgen Insensitivity Syndrome or PAIS. They are born with a wide range of phalloclitoral forms, from looking quite close to the male iconic form, to forms like that illustrated under “perineal hypospadias with chordee,” to looking typically female. Most have an intermediate form and are given childhood sex assignment surgery to one dyadic norm or the other. As usual, such surgery is traumatic, scarring, does not result in genitalia of fully “normal” appearance, and puts sexual sensation at serious risk. This probably explains why a third to half of individuals with PAIS grow up not to live as the sex they were assigned, while 80% of individuals with CAIS identify as “fully female.”

Those Not Pictured

Many bodies vary from sex-dyadic assumptions in ways that are not visible externally, so that they are rarely diagnosed at birth, such as variations in the sex chromosomes. We are told that “men are XY and women are XX,” but there are XX men and XY women who are not visibly distinct in their bodily forms from those with typical chromosomes. There are many individuals with XXY chromosomes, termed Kleinfelter's syndrome, with a typical male genital configuration but small testes—about 1 in 500 of people raised male turn out to have this intersex karyotype. People often only discover they are XXY when undergoing tests due to infertility, or sometimes in cases where they develop substantial breasts (“gynecomastia”). Another fairly common genetic variation is to just have a single X chromosome with no second sex chromosome at all, which doctors term Turner Syndrome. Having only 45 chromosomes instead of the usual 46 is associated with a host of physical problems, and the fact that the individual's gonads never develop is treated as secondary to the many physical and mental challenges the individual faces.

Other intersex conditions exist on a more macro level than tiny chromosomes, but are internal and so may go undiagnosed for years or for an individual's entire life. Included among these, ironically, are the only conditions deemed to constitute “true hermaphroditism” under medical taxonomies: the presence of an intermediate ovotestis, or even more rarely, of an ovary and a testis in the same person. I'll write more about “true hermaphroditism” in a later post.

Also not pictured are the bodies of people with an atypical sex steroid balance between the feminizing hormones (estrogens, progesterone, etc.) and masculinizing hormones (testosterone and its byproducts). Everyone produces all of these hormones, and requires both types for fertility and physical health, but those with bodies on the female size of the spectrum typically produce more feminizing hormones, and those with bodies on the male side typically produce more masculinizing hormones. Variations in this balance lead people with typically-female genitals to have higher levels of body and facial hair, muscle mass, likelihood of balding, and libido, and people with typically-male genitals to develop breast tissue, more curvaceous hips, etc. These variations are not termed intersex by doctors, but there is no logical reason why they should not be. Their intersex character is denied because most adults with such conditions have normative gender identities that match their genitals but are challenged by their contrasting secondary sexual characteristics. They and doctors together strongly assert that their variations do not make them any less male or female. While I agree that no one's gender identity should be deemed undermined by their physical appearance, I believe it would help all sex and gender variant individuals if society and medicine would acknowledge the prevalence of physical sex variance while supporting individuals in their gender identity assertions. Some intersex activists disagree, wishing to limit the conditions that will make a person “count” as intersex, and patrolling the boundaries of the community to exclude others as “wannabes.” Personally, I find this cruel and counterproductive. A woman with a beard lives a life in which her sexvariance is very visible, and saying she can't be included in a community of those with sexvariant bodies because she has typically-female genitalia does not make sense to me.

Another category of hormone-related variance includes individuals who produce low levels of sex steroids and whose bodies do not change much at the usual age of puberty. Such individuals are almost always treated with sex steroid therapy, without presenting them with the option of living in their androgynous bodies medically unaltered.

Finally, let me note that this catalog of intermediate bodily forms is not exhaustive. In my understanding, anyone whose body varies from the iconic male or female dyadic norms is sex variant, cannot be wished out of the intersex rubric by tricks of medical terminology, and should not be excluded from intersex community by gatekeepers.

We need society, the medical field, and intersex communities themselves to acknowledge that nature provides humanity with a wide range of forms, so that all of our bodies can be recognized as valid. Unless there is an actual rare functional problem, our bodies should not be altered in infancy, and only those functional problems should be addressed. Our genitals should be altered only if we ourselves request it, to make ourselves comfortable in our own skin, not to make society comfortable by our medical erasure. Society must come again to embrace the diversity that is nature's gift to us.

The Phalloclitoris: Anatomy and Ideology

This is a diagram of our shared heritage--yours and mine. It is a drawing of the genitalia we all start out with in the womb.

The Western medical establishment is deeply invested in the ideology of sexual dyadism: the idea that there are two very different sexes with two very different sets of genitalia. When children are born with genitals that are intermediate between the two, it is called a "malformation" and treated as bizarre and in need of immediate "correction." My earlier posts explain how this causes great suffering for intersex people. What I want to write about today is how the language we use and the diagrams doctors draw to illustrate genitalia hide the similarities between everyone's genitals. I believe that if we use more accurate language and diagrams, not only will we all understand eachother's bodies better, but the treatment of intersex individuals will improve.

Everyday Understandings of Genitalia

In the U.S., we live in a society that believes in two "opposite" sexes, men and women. Tell average Americans that sex is actually a spectrum of differences, and that there are societies which divide this spectrum into three or more sexes, and they'll just look at you funny. This is not because Americans are ignoramuses--it's just what we learned at home and were taught at school. Men have penises and testicles, children are told. Women have . . . well, women are presented as more complicated. Often children are told, "men have penises, women have vaginas." But then they learn at school (or in schoolyard talk) that the vagina is "the hole where a penis can go," but there are more parts to the female anatomy, and the most sensitive bit is the clitoris. By high school biology class most of us have dutifully learned that the technical term for the female genitalia is the vulva, made up of not only clitoris and vagina but labia minora and majora, the inner and outer lips, and that inside women have ovaries and uteri. What we are taught about male anatomy remains simple: men have a penis and testes. From this anatomical distinction we are taught to understand people as falling into two camps: straightforward, goal-oriented, insensitive men and complicated, vulnerable, sensitive women. That's gender dyadism, American style--the fodder for endless TV sitcoms.

What we are not usually taught is that that all humans start out in the womb with the same initial genital structure. This is certainly studied by embryologists, if not familiar to the general public, and I will give a basic tour in this post. I'm not going to use the language embryologists do, though, because I find it very odd. They refer to the initial human form as the "indifferent stage," often say that the genitals "appear female," yet term the sensitive end of the genital structure the "phallus." The truth is that we all start out appearing neither female nor male, and we certainly don't start out with penises. We all start out intersex. Our initial form (which some of us retain) is pictured at the top of this post. Let's examine it.

Human Genital Development
We all begin life with genitals that have four basic external elements. At the top is the part numbered 1 on my drawing: the sensitive end of the phalloclitoris, which can differentiate into the head of the penis or clitoris. In the center is structure 2: an inset membrane that can widen or can seal as the fetus develops. It will form the urethra, and the vagina, if any. Around it is structure 3, which is capable of differentiation into either a phallic shaft, or clitoral body and labia minora. And at the outside is the fourth part, the labioscrotal swellings, which can develop into labia majora or a scrotum.

There is a lot of variation in how each of the four basic parts of the genitalia develop from person to person in all of us. For example, we acknowledge with a lot of rib-elbowing the variation in penile size. Variation in the size and shape of genitalia, and in other parts of the body, is part of human diversity. Surgeons are well aware that livers and lungs and blood vessels vary a lot between individuals, and may look quite different from an iconic anatomical diagram. But we rarely care about having an unusually shaped liver. The shape of genitals, however, is given huge cultural weight, because we pin our commitment to dyadic gender roles on them. We look at the shape of a newborn's genitalia and project a future of dresses and diets and talking about emotions, or sports and strength and getting under the hood of a car. We do know that people are complicated. Most of us want to be more than walking gender stereotypes. Still, we understand people through the lens of dyadic gender difference, and intersex people call that into question. When we see a baby born with intermediate genitalia, and can't project a future for them based on our well-known gender narratives, people in our society--including doctors--freak out.

Part of the reason our culture reacts so poorly to intersex people is that doctors have spent the past 75 years or so erasing the bodies of people like me. I'm referring not only to the fact that doctors surgically alter our genitals, nor only to the fact that we're given an "M" or an "F" on our birth certificates, but to the fact that anatomical illustrations don't illustrate our anatomies. Medical drawings and medical language obscure our existence. And since I want doctors and parents and society at large to stop freaking out and erasing us, I want that to change.

Anatomical Illustrations of Adult Genitalia
Variation in the shape of genitalia is a fact of nature. Some genital variations are labeled intersex conditions by doctors, and considered unacceptable malformations that must be "corrected." Other variations doctors insist with equal vehemence not to "really" be intersex. There is little logic to this if you look at it from the perspective of physical health or function. Instead what seems to matter are ideologies: first, an insistence that all people must be "really" male or female; and second, an anxious commitment to associating men with big penises. And this is visible when you examine anatomical drawings.

Let's look at how doctors portray adult genitalia. Anatomy drawings in Western medicine present two and only two types of "normal" genitals. I don't have permission to post copyrighted medical illustrations, but a sample female genital diagram can be see here, and an example of a male genital diagram here. These drawings of dyadic sexual anatomy could be critiqued in many ways, but for now let's consider just one thing: the way the phalloclitoris is portrayed. In the female drawing, it's presented as a tiny clitoral dot, with the label pointing at a spot the size of a small pea. In the male drawing, it's presented as a huge penis, shown in the illustration I've linked as extending beyond the testes, apparently 8 inches or more in length even in its flaccid state. To put it plainly, the "normal penis" in this medical drawing is porn-star sized rather than average, and massive in comparison to the petite "normal clitoris."

Not only do these medical illustrations exaggerate sexual differentiation, they obscure rather than illuminate shared anatomy. Note that only the tip of phalloclitoral structure protruding from the foreskin or "hood" is labeled "clitoris." In fact, the phalloclitoris is similar in size between people at all points on the sex spectrum. In people with genitals that conform closely to the male end of the sex spectrum, the structure I've labeled #3 above merges into one erectile column. "Men" get a "penile shaft." In people with genitals that conform closely to the female norm, the two sides of the structure spread apart and surround the labia majora. "Women" get . . . well, what do you call that? Anatomists call these two feminized sides of the phalloclitoris the "clitoral crura," a term that most laypeople have never learned at school. Just like the penile shaft they are made of several inches of spongy tissue that fills with blood and erects during sexual excitement. You can see an anatomical illustration here (look at the part labeled "crus clitoris," the singular of "crura" in Latin). As you can see, the phalloclitoris is actually quite similar in men and women. The tip bends down in women and the two sides are joined together in men, but the basic structure is the same.

You would imagine that anatomical drawings would illustrate all of our genital structures to increase understanding. But do a Google image search for "female genital anatomy" and you'll see hundreds of images that look like this--and just one image in the first 10 pages that shows the crura. The anatomical illustrations that are used on educational and medical websites conceal rather than illuminate the similarities in everyone's phalloclitoral anatomy.

Do a Google search for just "genital anatomy" and you see dyadic illustrations of two very different types of genitalia. You don't see the shared embryonic anatomy from which we all develop, you don't see how all people have similar phalloclitoral structures as adults, and you don't see the wide spectrum of adult genital forms that exist. You see the ideology of sex dyadism, rather than the fact of the sex spectrum.

The Moral of the Anatomical Fable

In my next post I will discuss the common variations on the human genital theme, and why some and not others are called intersex conditions by doctors. What I want to conclude with today is the fact that language and the images scientists and doctors use exaggerate the differences between "normal" male and female genitalia. In a culture where people believe genitals determine gender, this makes men and women seem in general more different, more alien from one another, harming us all. And for intersex people, anatomical drawings and language present us as bizarre, inexplicable freaks who require medical "correction."

We need to change the language we use. Yes, sexual differentiation of bodies happens. The average person who was assigned male at birth has smaller nipples than the average person who was assigned female at birth. But we call the erectile tip of the areola a "nipple" whatever the sex of the person it adorns. A phalloclitoris is a phalloclitoris, erectile and sensitive--no matter if the person possessing it is deemed male, female, or intersex. In simple terms, some of us are more "outies" and some are more "innies" and some right in between--but we all share the same genital structures. You have a phalloclitoris, and so do I. We are all variations on the same bodily theme, and there is no need to react to intersex bodies with pity or horror.

Five Myths that Hurt Intersex People

I've had conversations with some intersex acquaintances recently about painful situations in which (nonintersex) people have accused my friends of not "really" being intersex. Besides revealing how rude people in our society can be about policing sex and gender, what these conversations have illustrated are some central myths about intersex status that come up over and over again. It's these that I will address in this blog post.

Myth 1: Intersex people all have intermediate genitalia

Imagine this: you're an intersex person, nervous about dating and finding a partner. You work up your courage to disclose your status to people you're interested in, and after a series of them seeming polite but disinterested in dating, you finally meet a guy who expresses interest. You date for a while, and get to the point where the clothes come off. Your boyfriend gets a good look at you naked, accuses you of "making up that story of being intersex" because your body looks female to him, and breaks off the relationship, leaving you feeling misunderstood and ill-used.

Many people are intersexed in ways that are not visible to their partners. For example, an individual with AIS (androgen insensitivity syndrome) is born with internal testes but genitalia that look typically female. Intersex people born with visibly intermediate genitals are often subject to infant sex assignment surgery, another reason why our bodies may not appear visibly intersex to others.

What disturbs me about incidents in which a partner seems interested in dating an intersex person until the clothes come off is that it generally reveals that the partner was fetishizing the intersex person--only interested in them for their "exotic" body. In the situation described here, the boyfriend wanted to have sex with someone who looked genitally intermediate generally. I've also heard stories from intersex people whose genitals are visibly atypical about how a partner lost interest in them when the clothes came off because they didn't see the kind of "hermaphrodite" genitals they'd dreamt of, with a big penis and a vagina (a configuration almost unheard of in real life, but popular in pornographic fantasy). It's depressing to find out your date wasn't really interested in you, but in playing with some fantasy set of genitalia.

Myth 2: Intersex conditions are always diagnosed in infancy

Here's another unfortunate scenario: a person is having infertility problems, so they visit some doctors. They receive a diagnosis and turn in shock to an online gender forum to post "I was just diagnosed as intersex." Somebody responds, "Stop trolling this blog. You're not really intersex--intersex people all know what they are from childhood. You probably have sick fantasies or think saying you're intersex will give you an excuse to gender transition without controversy." The non-intersex person is accusing the intersex individual of being a non-intersex person exploiting intersex individuals, which is pretty ironic.

As noted above, many intersex conditions aren't obviously visible in external genitalia. That means that people may not find out about their intersex status until quite late in life. While the experiences of late-recognized intersex people are different from those of intersex folks diagnosed in infancy, they are not "less" intersex, and have to deal with physical and psychological ramifications for which they need support.

Myth 3: All infant sex-assignment surgery is aimed at creating "female" genitalia

Imagine this situation: you were born with intermediate genitalia but surgically assigned male at birth. However, you grew up hating your male sex assignment, and so you transitioned to female. Your experience has given you a lot of empathy for people viewed as gendertransgressive, so when you notice that a friend of a Facebook friend identifies as genderqueer, you write her a nice message and offer her friendship. She refuses your offer and writes you a nasty note back about how she knows you are lying about being intersex, since "all intersex children are made into girls." She accuses you of being a stalking, posing, creepy man-in-a-dress. Ironic and sad, isn't it--that a woman who identifies as breaking down the boundaries of sex and gender is policing those boundaries so rabidly and wrongheadedly?

It is true that intersex infants are disproportionately surgically assigned female, based on the appalling medical aphorism, "it's easier to make a hole than a pole." But some intersex infants are surgically assigned male--usually when they have at least one external testis, but sometimes under other conditions. The myth that this "never happens" leaves intersex people assigned male at birth open to constant suspicion and exclusion, increasing the difficulties they have to face.

Myth 4: Intersex people should be genderqueer

This myth comes up again and again in academic, activist and feminist circles: that intersex people, being neither male nor female in physical sex, must be genderqueer and androgynous. We're supposed to be standard-bearers for the fight to subvert artificial dyadic gender categories. Encountering an intersex person with an ordinary and "boring" masculine or feminine gender identity who doesn't look at all androgynous, these activists express puzzlement and disappointment--and in private, speculate that the person must have some minor, mild intersex condition, so they are not "intersex enough" to be insightful.

Intersex people face pressure from doctors and families and society at large to genderconform. Facing the opposite pressure to gendertransgress--subversivism-- is just as unfair. Yes, most intersex people open enough to disclose our sex status agree that it is damaging for our society to insist that everyone must identify as male or female. But we live in a society that understands gender dyadically, and like non-intersex people, we commonly identify as masculine or feminine.

Myth 5: "Real" intersex people are not genderqueer

Frustrated and upset by pressure from gender activists to gendertransgress, as descibed in Myth 4, some intersex people have created a reactionary opposite myth: that "real" intersex people have no interest in subverting dyadic gender understandings of male and female. These genderconservative individuals often don't actually identify as "intersex" but as "people with DSDs (Disorders of Sex Development)." And they go around arguing to institutions that "real" intersex people don't identify as genderqueer--that people who say they are intersex and argue for third gender categories and the like are posers, probably crazed feminist zealots or deceptive trans people.

What makes the myth that intersex people are never genderqueer particularly painful to me is that it is spread by members of our community. To undermine your own intersex siblings and deny their identities is counterproductive, pathetic, and cruel. Many intersex people identify as typically masculine or feminine people, but there are plenty who do not do so, and like all genderqueer people, they face a lot of social bias. We have no duty as intersex people to be genderqueer, but I see a strong moral imperative for us to support people who do have genderqueer identities and manners of selfexpression. There are enough hurtful myths circulating about intersex people already. We don't need to add one of our own to the mix.

Viewing Intersex Genitalia (Note: Explicit Artwork Included)

Disclaimer

This is a drawing I did of the genitals of an intersexed person. If you don't wish to see explicit material, please skip this post. If you are an intersex person or an ally of ours who is concerned that posting images of intersex people's genitalia is abusive, please read my previous post. I discuss at length the many ways that photographs of us are exploited by medical practitioners and others, and why I believe humane images are necessary. Thanks.

Does a Picture Paint a Thousand Words?

When you look at the drawing above, what do you see? I see a set of external genitalia, an intersexed set that falls pretty near the center of the spectrum of male-to-female genital arrangements. Most people in our particular culture and historical moment apparently see something else. They see. . . something wrong. They want to know what it means. They want to be told whether these bits belong to someone who is "really a man" or "really a woman." And the authority they turn to to answer this (impossible) question is not the person possessing the genitals, nor regious authority, nor social scientists, but the medical profession.

Doctors get a lot of prestige from being the people who get to interpret life's mysteries for the masses. And they have an answer. I'll tell you what that answer is in a little while, but first, before what you see gets filtered through the medical lens, let me describe the structures you see depicted.

Anatomy of an Intersex Person

There are a great number of intersex bodily configurations, both internal and external. Our genitals come in many shapes and sizes--as in fact do those of people who are not categorized as intersex. What you see in this set of intermediate genitalia includes a phalloclitoris of intermediate size. Apparently many people experience something similar to a foreground-background illusion looking at the phalloclitoris (you know, like the illusion that looks either like two faces or a vase, which you can see here). They see a little penis, then a big clitoris, then a little penis. This flickering view has nothing to do with the genitals themselves, but with the lens of dyadic sex we've been trained to expect. This illustrates how we don't just see the world-in-itself out there, but a filtered view that imposes cultural understandings onto what we see.

The shaft and glans of this individual's phalloclitoris are mostly covered by a sheath of sensitive skin that we learn to call a clitoral hood or penile foreskin--again, dyadic terminology. The sheath of skin is bound down on either side, and the underside of the phalloclitoris is attached to the individual's body. Thus, when this person's phalloclitoris erects, it does not stand out from hir body but stays tucked close, pointing rearwards, as is typical for a clitoris.

At the center of this person's genitalia you see an invagination. It is fairly shallow, unlike the deeper vagina of someone with a classic female genital configuration. It is lined with delicate, lubricating skin. The urethral meatus ("pee hole") is in the central slit of the invagination.

Around the shallow invagination you see structures which are intermediate between labia majora (in female anatomic terms) or scrotum (in male terms). In this individual, there are testes that have descended and are held within the labioscrotum.

What Doctors See

As I've explained in an earlier post (here), doctors are the enforcers of sexual dyadism, and see all people as having a "true" or "best" sex, either male or female. Most often they like to assign intersex people to be female, and they remove or "reduce" our phalloclitori. They believe, though they tend not to say this, that it's better to be a female-assigned person with a surgically-constructed clitoris that feels nothing than to be a male-assigned person with a small penis. What they say, I kid you not, is that "it's easier to make a hole than a pole."

Doctors still take the "hard route" and attempt to construct a penis at times, and it's in individuals like the one whose genitals I've drawn here that they are most likely to do it: those with external testes. Internal ones they generally remove, claiming they pose a risk for cancer, but external ones they tend to leave in place. Finding external testes, doctors proclaim an intersex person to be "really male." Therefore, doctors looking at these genitals don't see a person of intermediate sex, they see a male with a "disorder of sex development" that they would term "perineal hypospadias with chordee."

On Hypospadias

As I've said, genitals exist on a spectrum. People with hypospadias run along the spectrum from maleformed genitals to the smack-dab center illustrated in this post. In people with what doctors call "first degree hypospadias," the genitals include typical testicles and a penile form that varies from the average male's only by having the urethra open, not at the center of the head of the penis, but on the underside of the head. Generally, the further down the shaft or perineum that the urethra opens, the more intermediate the genital form (doctors would say "the more severe the malformation").

Doctors almost always propose surgery for infants with hypospadias, even when there is only a small shift of the urethral opening. This causes scarring and loss of sensation, perhaps very mild, or perhaps leading to full numbness of the penile head and underside of the shaft. Constricted areas, holes that leak urine ("fistulas"), and recurrent bladder infections are common side effects, but are all deemed by doctors to be outweighed by the benefit of surgery. That benefit is basically avoiding the social mockery doctors presume is unavoidable for people with atypical genitals--the "locker room factor." Many male-identified people who had childhood surgery for minor hypospadias are very critical of the decision that was made for them, and, like intersex advocates, argue that no genital surgery should be performed unless and until a person grows up and chooses it. They'd rather have a penis with an off-center urethral opening that is fully sensate than a numbed phallus with an on-center urethra.

For people with perineal hypospadias, the consequences of surgery are more severe. Instead of having the functional genitals with which they were born--atypical but sensate intersex genitals that lubricate, erect, and experience pleasure--they wind up with small surgically-constructed penises that may be severely scarred and mostly numb. Instead of simply sitting down to pee, they may deal with multiple fistulas, a stuttering urine stream, and frequent bladder infections. In individuals with chordee, as in the drawing, since the clitorophallus is joined with the body, part of the glans and/or shaft will be cut off, left buried in the perineum or excised completely. Often there are multiple repair surgeries over the course of childhood--which is a source of stigma, not a shield from it. And significant numbers of these individuals grow up not identifying with the male assignment they were given, and in deep distress over the loss of genital forms they wish they had been permitted to retain.

The Moral of The Post

If people could look at intersex genitals and actually see them for what they are, a great deal of pain and suffering would be avoided. What you see in the image is an intermediate genital form, not warped female genitals or disordered male ones. When a child with intermediate genitals grows up, zie may identify as female, or male, or intersex, and should be allowed to decide what surgery if any is appropriate--but few get that chance. Wrong decisions are made for us all the time, and this happens in large part because our families have never seen genitals like ours before. They don't know how to interpret what they see because they have no context. So they turn to the doctors, who get a lot of prestige (and money) out of diagnosing us, selecting a dyadic sex for us, and surgically altering us without our consent. And not knowing anything about intersexuality, families go along. It's for this reason that I think it's so important that people see images of the full genital spectrum.

Artwork by Luminis, marker on paper, digitally manipulated. Copyright retained.