Just-So Stories about Hermaphrodite Fish

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Common is Intersex Status?

If you poke around the internet trying to find out how common it is for a person to be intersex, you may well wind up frustrated that nobody seems to have a precise figure to give you. You'll probably encounter some commonly-cited odds: 1 in 2000, or 1 in 2500. People have passed these figures around for a number of years, until, by repetition, they've come to seem generally accepted. I used to repeat these figures myself, before I learned more about how they were generated. Being born intersex is presented as rare; less common, say, than being born with Down's syndrome.

These estimates are off by more than a factor of 10.

A true, conservative estimate is that more than 1 in 150 people are born with intersex bodies. In this post, I'm going to explain why the true commonplace of intersexuality is so widely underestimated. And yes, I'll justify my 1 in 150 estimate by the end.

There are two main reasons reasons why nobody can give you an exact figure for how many people are intersex. The first is that there is nobody gathering this data. And the second is that in trying to come up with an estimate, people rely on medical diagnostic categories that purposefully deny that many people with sexually-intermediate bodies are “really intersex.”

Let's begin with the matter of gathering data on who is intersex. A central problem we run into is that nobody is funding a cross-condition population study of sex variance. This is the case in part, ironically, because being intersex is perceived as a rare thing. In addition, being intersex is framed as a “treatable medical condition.” Thus, there's little sense of intersexuality being an urgent matter to prompt government or private entities to fund a large exploratory study. But even if a large study of all physical sex variance were to be funded, you'd run into problems with people not wanting to disclose their bodily statuses. Some intersex conditions are obvious at birth when children have visible genital variance. But these children are immediately assigned a dyadic sex, male or female, on their birth certificates. The children and their parents are told by doctors that they must conceal the childrens' “defect.” With both the medical profession and our society at large treating intersex status as something freakish and shameful, people who are born visibly intersex are usually extremely closeted about their status, and don't want to be studied, outed, exposed. They are unlikely to want to take part in studies.

Furthermore, many people are intersex without it being genitally obvious. Some people are chromosomally sex-variant: they have a genotype such as XYY or XXY that is not associated with a significant disability, or they are XY women or XX men. Such people may never find out that they are intersex—after all, have you ever had your sex chromosomes screened? Other people have variant internal reproductive organs. I, for example, had an ovotestis, a gonad intermediate between an ovary and a testis. I'd been told I had a supernumerary ovary after pelvic exploratory surgery, and it was only years later, after I'd had my internal reproductive organs removed, that a pathologist informed me it was actually an ovotestis. What this illustrates is that in order to do a mass study of the frequency of intersexuality, you can't just rely on interviews and on existing medical records. One would have to do extensive medical testing, including biopsies, of all the people studied, which would be very invasive.

Even if you were somehow able to get a large, representative, random subpopulation of people to agree to be genitally examined, hormone-screened, genotyped, CAT-scanned, and to have their gonads biopsied, the frequency of intersexuality would be drastically underestimated. And that is because of the second problem I mentioned: that of medical diagnostic categories.

Let's think commonsensically and rationally for a moment.

What does it mean to be intersex? Logically, it means that a person has a body that is intermediate between the idealized male and female poles of the sex spectrum. All of us start out in the womb with an intersex form, having a phalloclitoris, labioscrotum, and ovotestes (you can read more about this in this post). It's expected that these should differentiate as we develop, but in fact one or more elements of the sexual anatomy may stay fully intermediate, or may differentiate only partially. Any person who has a body that is not fully sex-differentiated is, logically speaking, intersex.

But medical diagnostic categories are not logical, despite our ideology that they should be so. The majority of individuals born with intermediate sexual anatomies are not given an intersex diagnosis. I believe that what underlies this is gender ideology. And that gender ideology is this: masculinity is fragile, especially when it comes to what a man has in his pants. To live as a man with an inadequate penis is seen as intolerable. To have one's status as a “real man” challenged is viewed as psychologically crushing. Thus, doctors feel, if they were to categorize someone as intersex and then assign them male, they would be acting cruelly. Women, on the other hand, are perceived as more gender-flexible. After all, it's reasoned, a woman isn't shamed by wearing pants or taking on a power career. Viewing female-assigned people as more comfortable with androgyny and as better at dealing with emotional challenges, doctors believe that if they diagnose someone as intersex, they should assign them to the female category.

Thus, under current the current regime of medical diagnosis and treatment, the large majority of people labeled by doctors as intersex are assigned female at birth. People who are diagnosed under the rubric of “female pseudohermaphrodites" (a ridiculous term devised in the 19^th century for intersex people with ovaries and intermediate genitalia or a phallus) are assigned female, and their phalli are surgically removed. People who are diagnosed under the rubric of “male pseudohermaphrodites,” with internal testes and genitals that are intermediate or vulvic, are also assigned female, and their testes removed.

Under this regime, most people—including academic gender scholars, doctors, and even a substantial number of intersex activists—believe that “almost all intersex people are assigned female at birth.”

You'll find this statement oft-repeated, but it's not true. At least as many babies with sex-variant bodies are assigned male at birth. It's just that the majority of them are not diagnosed as “true hermaphrodites” or “pseudohermaphrodites.” Many, for example, are characterized as “real boys” with a "urethral malformation." The diagnosis they receive is “hypospadias.”

Hypospadias occurs when a person develops testes, but the phalloclitoris is intermediate in form. People with hypospadias can fall anywhere on the sex spectrum from having fully intermediate genital configurations to having forms little different from what is considered typically male. (You can find illustrations midway down the page here.) In cases of what is termed “first degree hypospadias,” the person has close to idealized male anatomy, but the urethra opens on the underside of the penile glans. As the degree of hypospadias increases, the opening is lower on the phallic shaft, and is larger and more vulvic in form. In perineal hypospadias, there is a substantial vagina, the phalloclitoris is intermediate in structure, and the testes may be internal. And the bodily variance is not limited to the external genitalia. Hypospadias is associated with an enlarged prostatic utricle, which may vary from a slight enlargement with low degree hypospadias, to a full-sized uterus in high degree hypospadias.

Rationally speaking, people with hypospadias are intersex. They share with other intersex people not only sex-variant anatomy, but the common experience of imposed genital-normalizing surgery in childhood, and the unwanted consequences of loss of sensation, infections, scarring and fistulae. And while individuals with mild hypospadias appear to be almost as likely to identify with their assigned sex as individuals with typical phalli, those with advanced degrees of hypospadias are much more likely to suffer from gender dysphoria with their male assignment. For medicine not to acknowledge that hypospadias is an intersex condition seems not only nonsensical, but often cruel. It may be true that people born with hypospadias who identify as male don't want to be publicly labeled intersex, just as male-identified people don't often buy T-shirts that say “Ask me about my erectile dysfunction!” or “Just call me Cocktail Wiener.” But our cultural obsession with male-classified people having large erections and unquestionable male status should not dictate medical diagnostic categories.

Now, here comes the kicker.

According to the CDC, hypospadias occurs in the U.S. in one in 125 children labeled as “boys,” or 1 in 250 births. In other words, if we looked only at this one condition, the minimum rate of intersexuality is 1 in 250.

There are other intersex conditions that are not diagnosed as such, though they are medically treated in the same way as other intersex conditions. Consider “clitoromegaly” and “micropenis,” the diagnostic terms for people with a clitorophallus of intermediate size. A child born with clitoromegaly is assigned to the female category, and today in the U.S. is given “clitoral reduction” surgery in the same way that a child diagnosed as a “female pseudohermaphrodite” is altered. Children born with micropenis in the U.S. are classified as boys, and must often endure surgical and hormonal interventions (sometimes even what is officially termed infant sex reassignment to female status). Yet individuals with clitoromegaly and micropenis are often not diagnosed as “offically intersex.”

So let us just look at individuals born with genitally intermediate bodies who are assigned male at birth. Micropenis occurs in 0.6% of male-classified people, or 0.3% of the population. Hypospadias occurs in 0.8% of male-classified people, or 0.4% of the population. Just looking at these two conditions, 0.7% of the population is born sex-variant. In other words, translating to odds, 1 in 142 people has either hypospadias or micropenis. That's more than 1 in 150.

We now see what happens when we employ the rational rule of classifying anyone who is genitally, gonadally or chromosomally intermediate as intersex. We logically include people with hypospadias and micropenis in the intersex category instead of excluding all conditions in which infants are assigned male. Now, for the sake of argument, let's just accept at face value the assertion that all other intersex statuses are so rare that the chances of having any other variation in gonads, genitals or chromosomes is 1 in 2500. I consider this extremely unlikely, but we'll just go with it. In fact, for the sake of our argument let's accept the ridiculous assertion a medical student once made to me: that there have only been 7 “real hermaphrodites” ever encountered in all of recorded medical history. By this logic, the chance of having any other intersex variation is 1 in a billion, or to simplify, basically 0. But we're still left with a minimum of 1 in 142 individuals having an intersex body.

That puts being intersex about on par with the likelihood of having green eyes.

Personally, I believe the rate is much higher. I do think it's unlikely we'll ever come up with an unquestionable exact number of intersex people, even if we get study funding and widespread permission from study populations, and even if medical diagnostic categories cease to be so irrational. Sex is a spectrum, and any way we slice up a spectrum is arbitrary and open to debate. (I remember my mother and grandmother perpetually arguing over whether the color turquoise was “really blue” or “really green,” and one could have similar endless arguments over the point at which an intermediate phalloclitoris is sufficently large-headed to “count” as a penis or sufficiently small-headed to “count” as a clitoris.) But at a very conservative minimum, more than 1 in 150 people have sexually intermediate bodies.

So the next time someone tells you that intersexuality is extremely rare, tell them otherwise. The next time you see a book about pregnancy that talks about uncommon complications and rare infant differences but never mentions how often babies are born intersex, raise a fuss. If you hear the old saw that “all intersex people are assigned female at birth,” clear up that misunderstanding. Be aware and help make others aware that the problems facing intersex people are not sad rarities, but burdens faced by many (over 2 million in the U.S. alone). And if you yourself are intersex and living a life in closeted shame, I urge you to stop believing you must live your life isolated and alone. You have a lot of siblings out there.

Intersex Fertility

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

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

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

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

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

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

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

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

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

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

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

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

It's time for some more sophisticated thinking about intersex fertility.

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.

Do I Have the Right to Marry Anyone?

On Sexual Identity and Intersex Experience

I'm married. I wonder if I'll be sent to jail.

DOMA, the Defense of Marriage Act, states that the U.S. federal government defines marriage as a legal union between "one man and one woman." My home state of Wisconsin goes further, providing that residents other than "one man and one woman" who go out of state to marry can be fined up to $10,000 and/or imprisoned for up to 9 months.

My spouse and I got married out-of-state.

The law scares me--because I'm intersex by birth.

My spouse, for whom I thank my lucky stars, is also intersex. We have very different bodies, different "conditions," but we share key experiences that bind us closely. And one of those shared experiences is a constant feeling of unease with regulations and categorizations--marriage laws, for example. If you were born neither male nor female, and you were looking at laws banning marriage unless it joined "one man and one woman," how would you feel? Unacknowledged, uncomfortable, socially unmoored? The people who wrote these discriminatory marriage laws had other aims--the existence of intersex people probably did not cross their minds when they were putting the bills together. But that's how a million regulatory regimes impact us. You are required to declare a dyadic sex, supposedly to protect your identity or serve your needs. That's why you have to check off an "M" or an "F" box to get a driver's license, or open a credit card account, or fill in a Facebook survey. True, these checkboxes conflate together physical sex and gender identity. I'm intersex, but my gender identity is masculine, so I can just check the "M" box on the Facebook survey about blue jeans.

But marriage is different. There's an inquiry into your "true sex"--supposedly to protect society at large.

The furor focuses on "same-sex marriage."

Conservative opposition to "homosexual activism" is what has driven the enactment of DOMA and the 29 separate state laws limiting marriage to "one man and one woman." I'm sure you're familiar with the rhetoric, which tends toward Biblical one-liners: "Male and female created He them;" "God created Adam and Eve, not Adam and Steve." There's the constant quotation from Leviticus, "You shall not lie with a male as with a woman. It is an abomination" (with the constant nonquotation of other passages from Leviticus, like the prohibition against wearing fabric mixing linen with wool, or eating pork, or trimming one's beard).

According to this simplistic interpretation of the Bible, God made men and women to be opposite and distinct, intended for procreative marriage, with a husband leading the household and a wife practicing submission to him. Heterosexual marriage based on these principles is said to be the foundation of society. Straying from it, we are warned most stridently, will undermine both morality and social order.Advocates of same-sex marriage have written many eloquent defenses of allowing gay- and lesbian-identified couples to wed. I certainly agree with them that male couples and female couples should be able to marry.

But where do I fit in this picture, as an intersex individual?

Last year I had a conversation with the leader of a proselytizing Christian group that had taken over the central plaza on my college campus. They were holding up signs saying that any sex outside the context of a marriage between one man and one woman damned a person to hell. I'll give them this: they were coherent in their sexual beliefs. They were also holding up signs about masturbation earning one eternal damnation (an assertion that did not win them a lot of converts in the college audience).

I stepped aside with the leader, and asked him respectfully what his religious precepts would advise for me. I explained that while I lived as a man, and he saw me as one, I was born with an intersex condition and was assigned female at birth. Since I was neither male nor female, how was I to follow a command that marriage only be contracted between a man and a woman?The religious leader stared at me for a bit, then rallied. He said that he wanted to tell me that he had great pity for me, and that God did not intend that I be born intersexed. "Birth defects," he explained, "exist because of Adam's fall. Original sin warped God's creation, and that's why tragedies such as the birth of a baby with crippled legs or like you occur." He explained that when Jesus came again, all of this disorder would be purged, and there would be no more people like me. I mustn't be angry at God but at sin for putting me in my position.

I told him that I believed that I was born exactly as the universe intended, and was not angry at God. What upset me was how I was treated by my fellow human beings. In any case, given that I did exist as an intersex person, whom did he believe I was permitted to marry?

He asked me what the doctor had put on my birth certificate, and I said "female." He gave me a grave face, and told me, "I'm sorry, but then that is what you are. You may look like a man but you are not, and you can't marry a woman. It's like the case of a transsexual, even though it is not your choice." So, according to this religious leader, sex assigned at birth governs marriage law, and there can be no sex transitions, for intersex people or for those born with normative genitalia. (Nonintersex trans people get the extra distasteful twist of the lip for a "choice," but the end result is the same.)

I then asked the religious speaker if he thought I should marry a man. He looked very uncomfortable and just shook his head. I said, "So you don't think I can marry anyone?" He suggested that I dedicate myself to God's will and eliminating sin rather than dwelling on my personal situation.

I guess that's what monks and nuns do: dedicate themselves to God, and live a life of celibacy. And since he didn't think I could marry anyone, and sex is only allowed in marriage between a woman and a man trying to procreate, celibacy is what he felt God required of me.

In the parlance of my Jewish ancestors, Feh.

I did ask him one more thing: why did he think that the doctors had picked the "right" dyadic sex for me? Couldn't I be trusted to look into my heart and know myself better than they? He just said that doctors are the ones who know, because they have the technology and the tests.

I don't know when or how doctors became the oracles of divine will for good Christians. In fact, I'm sure that when doctors declared that masturbation was healthy, the members of the group I encountered rejected that promasturbation prescription vehemently. . .

The majority of Americans would see the group I encountered as rather extreme. Yet the majority of Americans have enacted marriage laws that reach the same conclusion for intersex people: marriage is only acceptable between a "man" and a "woman." The fact that I'm neither by birth is some sort of unfortunate, bizarre accident. Doctors can be relied upon to pick the right sex for intersex babies, and that should clear the whole problem up.

But even doctors aren't so sanguine.

Doctors warn of a "risk of homosexuality" for babies born intersex.

Yes, you heard that right. Just read about some "DSD" or other and you'll see it there. Take congenital adrenal hyperplasia, or CAH, which is often manifested in the birth of a child with a penis outside and uterus and ovaries inside. Medical texts regularly state that "even with surgical and pharmacological treatment, CAH girls are at risk of homosexuality." In fact, there is now a highly controversial prenatal treatment program led by endocrinologist Dr. Maria New, intended to influence genital growth in CAH XX infants, so that they're born looking more like a typical female--and it is being reported not as an attempt to prevent intersex births, but as an attempt to "prevent homosexuality." You can check that out here. What a confusion of intersexuality and homosexuality! (And how eugenic. . .)

I have to ask you, from the perspective of birth sex, how can an intersex person be homosexual--unless they only have sexual relationships with other intersex people? Of course, birth sex does not dictate how sexual orientation is experienced . . . but doctors misapprehend how this works.

What the doctors really mean with regard to children born with XX, CAH is this: they take babies born with what are often totally average-looking penises, but internal "female" organs, and they cut their penises off. (The call this "clitoral reduction" nowadays.) They prescribe the children testosterone-suppressant drugs. They tell their parents, "See, you have a girl!" But the parents know the children are intersex--they saw them born with phalli. The children know they're intersexed--they bear the scars, they take the daily meds, and are forced to show their genitalia to doctor after doctor. Of course these children often grow up with gender identities and behavior that differ from "normal girls."

Apparently we intersex people often freak doctors out once we're not cute little tots over whose bodies they have vast power. They take an intersex baby with CAH, give hir sex assignment surgery, and want to believe that having sculpted a vulva-shape in hir flesh they'll have guaranteed hir a future of "normal womanhood," stereotypically defined as involving no great interest in sports, but lots of interest in fashion and boys. Sometimes their patients grow up into the pink feminine heterosexual icons of the doctors' imagination, expressing nothing but gratitude for the removal of those embarrassing "pseudophalli."

And sometimes CAH intersex patients show up in the doctors' office as depressed or angry teens in short hair and jeans. Maybe they identify as male, or as genderqueer, or as tomboys--doctors don't seem to ask about gender identities or if anyone wanted to keep that penis they had been born with. What they do ask about is sexual activity, and if the patients are involved with boys or girls or both.

The data they collect is pointless.

Without knowing gender identity, you can't tell someone's sexual orientation. Take two people with the same CAH bodily configuration, and one can grow up to identify as female and the other as male. If a person identifies as male and only wants female partners, his sexual orientation is heterosexual. But the doctors will label this person "homosexual," because they assigned him to be female, and they don't ask if that's the gender identity he actually grew up to have.

Doctors are acting just like the Christian sectleader I spoke with at my university. Intersexuality is a mistake, they say, unintended by nature. Doctors have the godlike power to divine the "right" dyadic sex for intersex babies, and correct their faulty bodies. And the "normal" thing for these intersex children to grow up and do is to marry a person of the sex other than the one the doctors picked for the child.

What does this all mean for me?

My spouse and I were both born intersex. I was assigned female at birth, and she was assigned male (I escaped surgical intervention but she was surgically misassigned, to her lifelong regret.) According to the sexes doctors put on our birth certificates, we are a "heterosexual" couple, though we share a physical status. Had we both grown up to identify with the sexes we were assigned, our intersexuality would be invisible to society--as both doctors and Christian antigay activists would wish it to be. We could have married and disappeared into the suburbs. Biologically speaking, we would not qualify as "one man and one woman" for marriage, but nobody would ever have raised a stink, so long as we accepted our lot and kept quiet about our birth status.

But we did not identify with our sexes of assignment. Eventually, we both found the strength and resources to enter the gender transition process. This has come as a great relief to us both, though it hasn't made our lives easy (read my last post to hear more about that). If transphobia were not the huge barrier that it is, and gender transition services could be easily accessed, and insurance covered the medical expenses, and the legal hurdles weren't so high, my spouse and I could have done a simple if ironic do-si-do and would now be married as a man and a woman.

Gender transition being the long, drawn-out, expensive, legally-convoluted process that it is, however, according to our birth certificates, we're both "male." No matter that my spouse was never biologically male. No matter that she has breasts and gets a menstrual period. No matter that she has identified as female since the age of 3 or 4. No matter that her driver's license reads "F."  Because she already had genital surgery in infancy, and is considered a "poor candidate" for further surgery, and wouldn't want it in any case, given the sensation she already lost in the first round, she can't change her birth certificate, and in Wisconsin, sex for marriage purposes is based upon birth certificate sex.

So: one thing we're dealing with now, despite the fact that we live as a married man and woman, is we are currently, according to our birth certificates, in a same-sex marriage. At the time we got married, my legal documentation still listed me as female, so getting hitched was unproblematic--but at the moment we look different on paper. And since we went to San Francisco to get married, someone could now threaten us with that $10,000 fine and/or 9 months in jail Wisconsin law allows. We share this unhappy situation with other LGBT couples in Wisconsin who found routes to marriage, and I have great sympathy for them all.

Even if we were able to change my wife's birth certificate some day, and we're no longer a same-sex couple on paper, we won't be safe. Because we're open about having been born intersex. Because we gender transitioned, and people know that. Because we're visible, we'll always be vulnerable to harassment by some bigot who wants to argue we're not "one man and one woman" and try to invalidate our marriage.

Intersex people having to deal with marriage restrictions is not some abstraction or game.

It's nervewracking stuff, and it's my lived experience. Sometimes well-intentioned people who want to construct arguments against "same-sex marriage bans" bring up the idea of intersex people like some sort of abstract theory. Take, as just one example, this post entitled "Common Arguments Against Gay Marriage." A section titled "Hermaphrodites" poses intermediately-sexed bodies as a hypothetical and asks how "feminized" a "hermaphrodite" must be to be permitted to marry a man. The blogger gets excited about this just-so story, and states, "This is a type of sorites paradox. Traditional sorites paradoxes involve asking how many grains of sand you have to remove from a pile before it stops being a “pile,” or how many pounds a fat person has to lose before they are no longer “fat.” These are paradoxes because they involve characteristics which are vague — it’s not clear where a pile or fatness begins and ends."

Yes, this hypothetical of the Incompletely Feminized Hermphrodite follows the slippery slope, sorites paradox argument format. But we are not mythic creatures in some ancient Greek story Zeno might tell of arrows that get halfway to their targets. We are not some illustrative fable. In writing about intersex experience and one-man-one-woman marriage limits, I have to raise this issue, because I know there are other intersex people who are livid at how people who are supposedly our allies treat us--so angry that they think the intersex community should refuse to enter public discussions about how marriage restrictions affect us. I agree that we have been treated rudely, our bodies seized upon as fodder for arguments by people ignorant of our painful real life experiences. It's depressing.

But the fact that our lives have been appropriated by others should not silence us. And so I am speaking out, and asking for something simple.

I am a human being, and I ask for respect.

All bodies deserve respect. Intersex variations are not lusus naturae, medical defects, the wages of sin, or mistakes unintended by God. Sex is a spectrum by nature, and everyone's body is a gift.

All loving relationships deserve social support. To believe that it is ungodly of me as an intersex person to get married to a man or to a woman because the sex I was assigned at birth did not match the gender identity I developed--that is a failure to understand and embrace a God of Love. To grant or deny people the right to marry based on their sex or their gender is simply wronghearted. All people--straight and queer, trans gender and cis gender, intersex and dyadically sex-normative--should be treated with dignity when they commit to love.

For a person to be threatened with imprisonment for daring to marry . . . now that is moral evil.