Cis Gender, Trans Gender, and Intersex

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Hypospadias: Intersexuality and Gender Politics

If you are looking around for information about intersexuality, one of the first things you're likely to read is that "most intersex children are assigned female at birth."  This is in fact false.  

In the U.S. today, according to the CDC, one in 125 children assigned male at birth is surgically modified to fit that binary sex status.  The percentage of children assigned female at birth who are genitally altered in infancy to feminize their genitalia seems to be lower.  Exactly how much lower is very difficult to determine, since nobody is gathering the data we'd need to have.  The reason we know the 1-in-125 figure is because these children assigned male are all given the same diagnosis: hypospadias.  Hypospadias is the diagnosis given to most children born with intermediate genitalia who have external testes.  Rates of hypospadias have been increasing, and the CDC is collecting data due to concern about that.

The reason people continue to say that few intersex individuals are assigned male is that doctors term hypospadias a "penile malformation" rather than an "intersex condition."

I've written about this before in this post.  I noted there, "medical diagnostic categories are not logical, despite our ideology that they should be so. The majority of individuals born with intermediate sexual anatomies [and surgically assigned male] are not given an intersex diagnosis. I believe that what underlies this is gender ideology. And that gender ideology is this: masculinity is fragile, especially when it comes to what a man has in his pants. To live as a man with an inadequate penis is seen as intolerable. To have one's status as a 'real man' challenged is viewed as psychologically crushing. Thus, doctors feel, if they were to categorize someone as intersex and then assign them male, they would be acting cruelly.  Women, on the other hand, are perceived as more gender-flexible. After all, it's reasoned, a woman isn't shamed by wearing pants or taking on a power career. [Doctors view] female-assigned people as more comfortable with androgyny and as better at dealing with emotional challenges."  Because of assumptions about fragile masculinity and flexible femininity, doctors feel more at ease assigning children they designate as intersex female. Those they regularly surgically alter to conform to binary male sex norms, they wish not to label intersex.

I was contacted by some people after writing that prior post challenging my assertion that hypospadias is an intersex condition.  They countered that it was simply a minor displacement of the male urethra.  So I wanted to make my case more clearly.

Let's start with some illustrations.

All children start out in the womb with the same set of genitals, an intersex form.  As a rule I will not post photos of children's actual genitalia because it is exploitative, but in this case, I feel a medical image of the standard genital form of a fetus isn't going to cause additional emotional trauma to any particular child, so here's a photo:

Our society expects this intermediate genital form to differentiate before birth into two "opposite" binary sex forms (penis and testes, or vulva), but in fact, babies are born with genitals on a full spectrum between these two socially idealized poles.  Let's look at how medical professionals illustrate this sex spectrum.

When a child is diagnosed as having some form of XX, CAH, congenital adrenal hyperplasia, the sex spectrum is described by the "Prader scale," and the "stages" of the "condition" evaluated using this chart:

When a child with XY chromomes is diagnosed as having a form of AIS--partial or complete Androgen Insensitivity Syndrome--the sex spectrum is termed the "Quigley scale," and is illustrated like this:

  
You can see that both of these illustrations include 6 forms, although they number them in reverse order and with different numerals.  What they both show is that between a genital form considered typically female and one considered typically male, there is a common spectrum of intermediate forms.

This is equally true for children who are diagnosed as having hypospadias.   But medical illustrations of hypospadias are very different.  They do not picture the genitals as intermediate in form.

Instead of picturing the same range of in-between forms shown in the Prader and Quigley scales, medical illustrations of hypospadias variations show something odd: a carefully illustrated "normal penis" with a series of dots superimposed upon it to indicate the level at which the urinal meatus/ vaginal opening are located.  

 
The penis is always illustrated as erect, and often with a lot of illustrative detail to emphasize the "reality" of this imaginary ideal penis existing instead of the intermediate genitals actually present in intersex individuals who have external testes.

Let us be clear here.  A child diagnosed with hypospadias of an "advanced degree," be it termed perineal or posterior or scrotal, will have an intermediate phalloclitoral form with a substantial invagination, not a large, erect phallus with a dot at the bottom.  They'll look more like the Prader 2 or Quigley 4.  I'd illustrate such a child's genitals more like this:

Why would medical illustrations of intermediate genitalia be representationally accurate in the case of intersex children diagnosed under the rubrics of AIS or CAH, but inaccurate if highly detailed in the case of intersex children diagnosed under the rubric of hypospadias?  Only gender ideology can explain this.  Children diagnosed with CAH and AIS are routinely assigned female.  But children with hypospadias are surgically "corrected" to male, and to undermine the "adequacy" of a male's phallus is treated as untenable.  Parents (and doctors!) must be reassured by looking at the erect, large, ideal penises drawn in the hypospadias illustrations that the genitally intermediate flesh of the child they see is illusory, and that an excellent penis will soon be revealed by the scalpel.  

So: medical illustrations of hypospadias, and the medical assertion that it is not really an intersex condition, relate to our ideologies of masculinity.

The differences in medical approaches to intersex children routinely assigned female and routinely assigned male extend further than illustrations and terminology.  They also determine all the tests and evaluations the child will receive.  If an intersex child lacks external testes--the determining characteristic of a hypospadias diagnosis--that child is routinely subjected to a battery of tests: genotyping, endocrine screening, medical imaging scans.  This is not the case when an intersex child has external testes.  In fact, even suggesting that a child with intermediate genitalia but palpable testes receive any sex-related tests at all is considered "controversial" by doctors.  Since hypospadias is defined as a penile malformation that is not an intersex condition, why would anyone wish to test sex chromosomes, hormone levels, or internal reproductive structures?  It's presented as an unacceptable waste of time and money, in an affronted tone.  

In fact, individuals born with hypospadias do commonly have other sex-variant characteristics.  An example is the presence of what is termed a substantial "prostatic utricle," a uterine structure that may be small or full-sized that connects to the vaginas present in these children at birth.  While the "pseudovaginae" are removed and closed during infant genital "normalizing" surgery, doctors do not test for the presence of a uterine structure.  People diagnosed with hypospadias and their doctors generally only become aware that there is a utricle present if something goes wrong, such as the development of uterine cancer or painful cysts--and then usually by accident during imaging scans for some other presumed cause of the patients' symptoms. 

I want to note that many intersex people assigned female at birth complain of all the invasive tests and screenings and procedures to which they are subjected in childhood, so the fact that intersex children with hypospadias diagnoses avoid these is not necessarily a bad thing.  But not even thinking of checking for a uterine structure in someone born with hypospadias who presents to a doctor with pelvic pain could have very negative health consequences. 

It is clear is that intersex children diagnosed with hypospadias are treated very differently than children with other intersex diagnoses.  Rather than being treated as bizarre and interesting medical cases that require a lot of medical study and intervention, they are treated as normal boys with a little urethral displacement issue.

The thing that children diagnosed with hypospadias have in common with other intersex children is that they are subjected to genital normalizing surgery that can have many negative consequences.  Medical texts list as unwanted consequences of hypospadias "repair" surgery urethral fistulae, strictures, and diverticulae, recurrent urinary infections, "excess skin," hair-bearing skin, persistent chordee, erectile difficulties, erectile persistence, chronic inflammation, and a condition called balanitis xerotica obliterans.  Textbooks are oddly silent on the issues of loss of genital sensation that are very common, and the fact that children born with genitals in the middle of the sex spectrum are particularly likely not to identify with the sex they are surgically assigned at birth.

Some children who are diagnosed with hypospadias have genitals that are quite close to the binary male ideal in our culture.  For them, medical interventions may be fairly minor, and the side effects may be modest.  They are very likely to see themselves as typical males, and are probably unlikely to wish to be identified as intersex because they share our society's pattern of fragile masculinity.  I am empathetic with their position.  But we should be able to support the gender identities and dignity of people born with hypospadias who identify as men without resorting to inaccurate medical illustrations and illogical medical taxonomies.  

Hypospadias is an intersex condition.  The surgeries we perform on unconsenting intersex children without their consent have lifelong consequences.  These can be profoundly negative for children whose genitals are dramatically altered--something that intersex advocates decry all the time.  But we should also question why we routinely risk the loss of sexual sensation in the glans of the male-assigned child whose urethra is in a slightly atypical place.

All of us born intersex deserve to be recognized as such, and to be granted autonomy to make our own decisions about what "normalizing" surgical alterations we wish, if any.  Putting an end to the routine genital reconstructive surgery performed on the many thousands of children diagnosed with hypospadias each year should be considered an important point of intersex advocacy.

On Sex/Gender Checkboxes

Day in and day out, sex and gender minorities are boxed in by being confronted with sex/gender checkboxes. This starts the moment we are born, when a binary sex must be checked on our birth certificates: “male” or “female.” For individuals who are born with visibly intersex bodies, this requirement causes a crisis. Families and doctors make hasty decisions about which box they'll force us into, and we have to live with the consequences all of our lives. Having checked off a binary “M” or “F,” those with authority over our infant bodies often feel that trying to reshape our bodies conform to the box they've picked is unavoidable. Thus, genital surgeries are routinely performed, despite the deep unhappiness so many intersex people voice about the results as adults. Great pain might be avoided if parents were allowed to acknowledge our physical truth on birth certificates which included an intersex checkbox, or if the gender marker requirement were simply removed.

For people who are trans gender, gender transitioning is made traumatic in large part due to the checkboxes we must face daily. Binary gender markers are everywhere: on our drivers' licenses and passports, on loan applications and job applications, and on websites everywhere (from Facebook to shopping sites to online radio stations). Once you've checked off one box, changing it is bureaucratically and legally difficult—and sometimes there's no way to change it at all. This leads to all sorts of hassles and embarrassment, as we're “outed” in odd contexts. Worse still, if the gender we're living in doesn't match the marker on our ID, we're subject to being banned from flying, arrested by bigoted police officers, and denied employment.

For folks who don't identify with a binary gender, the world of checkboxes constantly denies our very existence. We go institutionally unrecognized, with no way to even try to say “I am here!”

Sex and gender minorities have some protection in institutional settings that bar discrimination on the basis not only of sex, but of gender identity or expression. But often, such policies are adopted with no follow-through on what it really means for a university or company or city to protect gender identity and expression. Unaware of our needs, administrators think only of ensuring that trans people aren't being kicked out just for gender transitioning. While this is certainly important, there are many more needs that must be addressed. And central among these are that sex/gender checkboxes protect the rights of sex and gender minorities.

I have written a Best Practices guide that is under discussion at my university. It lays out a plan for rewriting sex/gender checkboxes that is meant to address the needs of intersex, trans gender, and gender variant people, in this case, in a university setting. There are some inevitable compromises in it between institutional desires for simplicity and brevity, and our desires as individuals to have our identities recognized in all of their fullness and uniqueness. But I wanted to share it here so that other people who are looking for a guideline to use in seeking to better the way institutions around them limit sex/gender choices would have something to start with. It doesn't address the problem of birth certificates, for example, since universities don't issue them. It does, however, address the question of how sex and gender and sexuality should be measured in research in some detail.

Please feel free to share and employ at will.

Best Practices for Identification of Sex/Gender

Compiled by Dr. Cary Gabriel Costello

I. Foundational Principles

Institutions which commit themselves to protecting against discrimination on the basis of sex and of gender identity or expression (GIE) must give individuals the right to self-identify their sex/gender.

Whenever data are gathered about sex/gender, the rights of GIE minorities (intersex individuals, trans men, trans women, and individuals with alternative gender identities) must be protected.

II. Definitions

“GIE minorities” include intersex individuals, trans gender individuals (trans men, trans women, and individuals with alternative gender identities), and people with variant gender expression.

Intersex Persons

While it is common to believe that sex is binary—that is, that all people are born either male or female—in fact, sexual characteristics exist as a spectrum. There is a great deal of variation in chromosomes (XX, XY, XXY, XYY, etc.), hormones (relative levels of estrogen, progesterone and testosterone), secondary sexual characteristics (breasts, hair distribution, etc.) genital configurations, and gonads (ovaries, ovotestes, testes). Intersex people are individuals whose sexual characteristics fall toward the middle of the spectrum. Approximately 1 in 150 people are intersexed according to medical diagnostic criteria. Most are very private about this status, though some are public about it.

Trans Gender Individuals

Individuals whose gender identity does not match the sex they were assigned at birth are deemed trans gender. A trans man was assigned female at birth but identifies as male; a trans woman was assigned male at birth but identifies as female; a genderqueer individual may identify as neither male nor female. Trans gender individuals often transition to their sex of identification, though they may do so in different ways. Some transition socially by changing name, pronoun, and dress. Others also take hormones (testosterone or estrogen/progesterone) to alter their bodies. In addition, some get surgery to change their chests or genitalia. Because surgery is quite expensive, may not be covered by insurance, and because it carries serious risks, many trans gender individuals in the U.S. do not seek or are unable to access surgical transition services.

Variant Gender Expression

People of any sex or gender may have an atypical gender presentation—male femininity, female masculinity, or androgyny.

III. Best Practices in Collecting Data about Sex/Gender

The best practices for collecting data about sex/gender depend on context. If collecting data about sex/gender serves no purpose for the individuals from whom it is collected, then eliminating the question is the best practice. If data are being gathered to protect the rights and well-being of individuals, then individuals should be given self-identification options that allow GIE minorities to self-identify. These options include a shorter form for ordinary uses, and longer forms to be employed in research contexts.

Eliminating Unnecessary Requirements for Individual Sex/Gender Identification

There are many institutional contexts in which people are routinely asked to identify their sex/gender based on common marketing practices or institutional tradition rather than an intent to protect the individuals from discrimination on the basis of their sex/gender. (For example, this is a common requirement in registering to use website services.) In this situation, the best practice is simply to eliminate the unnecessary requirement of declaring sex/gender.

Standard Best Practices Short Form for Sex/Gender Identifications

In contexts in which data is collected order to ensure equal treatment and respect for all, information about sex/gender should be collected in a manner that protects GIE minorities. The goal in implementing sex/gender categories for general data collection is to protect the rights of all people, whatever their physical sex status or gender identity, including intersex individuals, trans men and trans women, and individuals with alternative gender identities. Thus, the inappropriate single question (“Sex: Male__, Female__”) should be replaced with a three-stage approach.

1. Gender identity: Woman __, Man __, Alternate Self-identification (please write in) ______________.
2. Do you have an intersex condition (disorder of sex development)? Yes__, No__.
3. Are you trans gender? Yes__, No__.

In order also to ensure nondiscrimination on the basis of sexual orientation, best practices add a fourth question unrelated to GIE:

4. Sexual orientation: Heterosexual __, Lesbian__,  Gay__, Bisexual__, Queer__, Pansexual__, Asexual__, Alternate Self-identification (please write in) ______________.

AVOID poor practices which undermine individuals' identities instead of protecting them. A common poor practice is to use a single additional checkbox: “Male__, Female__, Transgender___.” This is inappropriate for several reasons. First, it does not allow intersex individuals a way to identify themselves. Secondly, it discriminates against trans men and trans women by framing trans gender identification as incompatible with “real” male or female status. And thirdly, it does not allow for recognition of the distinct needs and identities of individuals who identify as neither male nor female.

Best Practices Long Forms for Research Contexts

Data about sex and gender are often collected in the course of research. If data are to be analyzed along the dimensions of sex and/or gender, two sets of needs must be met. The first relate to the rights of research subjects, who must be protected from harm, including the harm of discrimination on the bases of sex, gender identity or gender expression. In conducting research with human subjects, researchers will inevitably recruit research subjects who are intersex, trans gender, or variant in their gender expression, and are ethically obliged to treat them with respect. The second issue relates to the need of the researcher to have research questions carefully worded in a manner that subjects will understand and respond to in a reliable and valid manner.

Many scientific studies today continue to use “sex” as an independent variable, and measure this in a binary fashion. This is a methodological flaw, as well as discriminating against GIE minorities. It does not allow the researcher to measure what actually accounts for observed variance in the dependent variable: is it physical sex status, internal gender identity, gender-conformity or nonconformity? Just as a study that uses religion as an independent variable is improved when it not only identifies subjects as “Christian,” but allows the subjects to identify a more specific denomination, asks them how religiously observant they consider themselves, and inquires as to how often they attend church, increasing the sophistication of sex/gender questions improves study results.  The following measures are suggested:

1. What gender do you identify with? Man__, Woman__, Other (please write in the identity)________________.
2. What sex category were assigned at birth? Male__, Female__.
3. As far as you know, were you born with an intersex or sex variant body? Yes__, No__.
4. Please indicate how masculine or feminine you are in your dress and manner on the following scale: (1) very masculine, (2) moderately masculine, (3) a bit masculine, (4) androgynous, (5) a bit feminine, (6) moderately feminine, (7) very feminine.

In order also to ensure the study is not discriminating on the basis of sexual orientation, and to gather better data, best practices suggest that subjects also be surveyed on their sexual identity. Problems are often raised by the traditional method of asking subjects if they are “heterosexual, homosexual, or bisexual.” For example, people who are gender transitioning or who identify as neither male nor female are often unable to use these sexual orientation categories to classify themselves. Furthermore, it is well established that there is a difference between how many people identify their sexual orientation and the sexual activities in which they actually engage. This may be addressed through questions such as the following:

1. To whom are you attracted, sexually and romantically? (1) only men, (2) mostly men, (3) a bit more toward men than toward women, (4) equally toward men and women, (5) a bit toward women than men, (6) mostly women, (7) only women.
2. With whom have you been sexually involved? (1) only men, (2) mostly men, (3) a bit more men than women, (4) equally men and women, (5) a bit women than men, (6) mostly women, (7) only women.
3. Are the people to whom you are attracted (1) very masculine, (2) moderately masculine, (3) a bit masculine, (4) androgynous, (5) a bit feminine, (6) moderately feminine, (7) very feminine.
4. Consider the idea of a partner who identifies as neither male nor female, but as some other gender such as “genderqueer.” Do you find that (1) very appealing, (2) moderately appealing, (3) a bit appealing, (4) I feel neutral about it, (5) a bit unappealing, (6) moderately unappealing, (7) very unappealing.

Researchers who choose specifically to study GIE minorities should consider them a vulnerable subject pool for IRB human subject protection purposes. In cases of studies recruiting intersex, trans gender, or gender-variant subjects, procedures should be set in place to protect these vulnerable subjects, and the questions asked about sex and gender carefully designed to accord all subjects with full respect for persons. Confidentiality should be strictly protected, data collected in a location where subjects will not be at risk of having others see or overhear their responses, and information sheets listing appropriate support groups and links to mental health resources distributed to those recruited to participate.

Interphobia--Not Cured by Hiding Us Away

This terribly disrespectful cartoon depresses me.

It's from a blog entry entitled "10 reason why Caster Semenya is a man. . . she set to run in June anyway," posted this April by a guy named Anthony. Here's a link, if you really want to see.

When Caster Semenya's name first became an international headline, I wrote a blog post about her situation, and I'm not going to revisit the specifics of her case now. Read the older post here if you wish. What I want to address now is the problem of bias against intersex people, which, following the conventions of the terms homophobia and transphobia, I'm terming interphobia. The cartoon of Caster Semenya standing to urinate from a presumed male phallus is an example of interphobic humor.

Caster Semenya's case has served as a lightening rod for interphobia.

If you wander the world of internet humor, you'll find plenty of other examples like the post by Anthony I discuss here. Internet mockery of Caster Semenya draws its vitriol from a variety of sources--you'll find it laced with sexist insecurities about women with athletic prowess, transphobia from authors who presume that Semenya is an MTF trans person, racism in the form of assertions that if she were a "real woman" she'd have straightened her hair--there's a whole banquet of bias being served up. But there are specific elements of interphobia that lie front and center. There's a lot of prurient har-har speculation about her intersex genitalia, framing Semenya as someone whose genitals are on freakshow display. And there's castigation of Semenya for identifying with her sex of rearing.

What the cartoon I've shared from Anthony's blog post illustrates is rage at Semenya for identifying as female, iconically represented by which bathroom she uses. Thus Caster Semenya is shown both in a vulnerable position, at the toilet, and as smirking at the viewers as if daring them to do anything about the fact that she knows she is not a "real woman," illustrated by her standing to urinate. The text of Anthony's blog post is a list of body parts that he claims prove Semenya is "really a man," including even the shape of nostrils (!), but focusing most obsessively on the flatness of her breasts. "NO breast...naada, not even 1% breast, not even fat man breast...," he declares, and, making fun of a photo of Semenya in a dress, he says "they dress up the person into a woman....but they failed to give it a cleavage or breast."

It.

What Anthony concludes is that Caster Semenya is a man and should be running in men's races. He declares her a cheat by virtue of her intersex status, the sex she was assigned at birth wrong, and her gender identity as a woman unacceptable. Basically, Anthony wants to force Semenya to undergo gender transition against her will.

And Caster Semenya followed the rules.

There are rules we live under in our contemporary Western societies that I and many, many other intersex advocates have criticized. The rule that the spectrum of physical sex characteristics we are born with must be forced into dyadic sex assignments, often accompanied by unconsented-to infant genital surgery. The rule that we are supposed to grow up to identify with our sex of assignment. These rules, we are told, are for our own safety.

Doctors tell the families of genitally variant babies that without surgical sex assignment we will be treated as freaks, but surgery will protect us from pariah status. Some of us face traumatic "gender therapy" as children in an attempt to cause us to identify with the sex we were assigned, and again, our families are told this is for the best because it will protect us from ostracism. Our families are told to keep our status a secret. We're told to keep silent, fit in. Our intersex status will thus be erased, and we'll be safe.

Well, Caster Semenya was assigned female at birth, raised as a girl, and identifies as a woman. Her intersex status wasn't known to anyone at all--it wasn't even diagnosed until she was forced to undergo "gender verification testing" when some sore-losing competitors demanded it.

What this proves is that having one's intersex status secret is no protection at all.

We may pass as our assigned sexes--but at any time we may run into a circumstance under which our intersex status is revealed. We get in a car accident. We find ourselves with an ex with a grudge. We're thrust into the limelight, perhaps by winning a race. And we're outed--and thrust into the path of vicious interphobia. We face ER staff who take cell phone photos of our genitalia to send to their friends while we're unconscious, exes telling all of our Facebook circle that we're freaks, and random bloggers mocking us and declaring that we should be forced to gender transition.

The "solution" that doctors pose to the fact that intersex happens--to hide us all in the closet--does nothing to stop interphobia. In fact, it encourages it by making us vulnerable, isolating us from support, keeping us ashamed. The real solution is to fight interphobia directly. We need to come out, accept ourselves, and demand that others do the same.

Deaf Children, Intersex Children, and DSDs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intersected, Transsected: The Intersex / Trans Nexus

A troubled alliance

Intersex and trans people share some deep common experiences. Yet we often find ourselves prickling at comments made by people in the "other camp." As an intersex person assigned female at birth and transitioning to legal male status, I consider myself both intersex and trans, and I'd like to speak to what both groups share, and what divides them. Divides us.

Commonalities

The most fundamental thing intersex and trans folk share is that we suffer because we belie the ideology that dimorphic genitals determine gender. This is the belief that people are born with one of two possible genital configurations, and that gender identity is inevitably bound to this genital configuration. Penis = "it's a boy!"; vulva = "it's a girl!"  This is an ideology so basic that most people in our Western society rarely if ever question it. Then we intersex and trans people come along and call a fundamental belief into question. Genitals come in a spectrum of possible flavors. Gender identities are not determined by genitals. We are girls born with penises, or androgynes born with vulvae, or boys born with both testes and a vagina. And we make people nervous.

Freaking people out when it comes to sex and gender turns out to have serious consequences. We evoke shock and horror, distate and tittering, fetishistic dehumanizing desires. People fail to treat us as. . . people. Doctors poke and prod us, employers find excuses not to hire us, and idiots bash us. So: we share a common enemy. We suffer from the enforcement of the ideology that dyadic genitals determine gender.

Another thing intersex and trans people share is that we have a difficult relationship with doctors who have power over our lives. For people with intersex conditions, this often starts at birth, when doctors label us as defective and in need of surgical "correction." We are subjected to sex assignment and "corrective" surgeries without our consent. Then many of us grow up not identifying with our sexes of assignment, and join with our trans siblings in facing gatekeeping from the other side. People who identify with a gender that does not match our sex of assigmnent often want to alter our bodies, to reduce feelings of tension, and to get other people to recognize our deep internal sense of self. And we face a lot of hurdles. Medical insurance generally doesn't cover sex transition services--and they are expensive. Worse, to get access to them we have to run a gauntlet of medical gatekeepers. We need psychologists and doctors to grant us access to the hormones and surgery we want, and they make it hard for us, very hard. At every step we may find ourselves confronting, if not outright bigotry, a strange assumption that to want to do what we want to do, we must be mad. We have Gender Identity Disorder, considered a mental illness. Gatekeepers act as if we might well be utter psychos, and need to be tested, cautioned, challenged, as if anyone decides to face discrimination and violence on a whim.

Another thing trans and intersex people share is the way in which we are sexualized in a society with both Puritan and Dionysian strains. This is complex enough to rate its own post, so I'll set it aside for now.

Tensions: Intersex Complaints

Something that makes a lot of intersex people grouchy is encountering trans folk who think we have it easy. There's a belief some trans people hold that doctors and people on the street are understanding of intersex people's needs. More particularly, these trans people think that if they had an intersex diagnosis, they'd get easy access to medical transition services, and have their transition honored by employers, schools, the DMV, and other institutions.

But this is not the case. Doctors and families make decisions on behalf of infants with visible sex variance, and having subjected us to surgery without consent, they don't want to hear that we're ungrateful. As for schools and employers and DMVs, we have the same relationship to them if we want to undo a sex assignment that trans folk do when they seek sex reassignment.  Intersex people are not "fast-tracked" in medical or legal gender transitions.  Our transitions are not paid for by insurance--only those medical procedures that would make our bodies conform to our assigned sexes are covered.  In fact, intersex people can face higher hurdles in dealing with diagnostic gatekeeping, as the GID diagnosis used by psychologists to green-light a transition is understood by some as excluding intersex people.

Nobody wants to hear their suffering dismissed. Intersex people feel hurt when trans people treat living with intersex status as a walk in the park. It is true that *some* doctors and families and coworkers are more comfortable treating intersex people as tragic victims than they are when they look at trans people and see them as having "chosen" to be freaks. But it's not true of others.  And it doesn't make accessing transition services any easier.  Furthermore, treating intersex people as "lucky" glosses over all that intersex kids often suffer in childhood, with multiple surgeries, humiliation, and familial silence.

Another thing that bugs intersex people is when trans people try to latch onto intersexuality as a way to explain their identities. This is especially common among people just coming out of the closet. Trans folk who've been living in denial and are reaching the point where they can't bear it any longer often search the internet, find one of the few intersex support sites, and start posting about how they must be intersex: "I must have some intersex hormone imbalance--I hate sports and cry easily." "People have told me my clitoris looks kind of big and I want to have sex with girls, so I must be intersexed." It makes it hard for intersex people to use the boards at times. Interfolk get tired of explaining the difference between intersex conditions, sexual orientation, and gender dysphoria to nonintersex people who are looking for an explanation for trans identities..

Tensions: Trans Complaints

Trans people are less likely to feel irritated by intersex people's actions, because they usually aren't aware of meeting any. Intesexed people are instructed from youth to go stealth, and we're often invisible. But there are legitimate gripes that trans people can have with intersex folks.

Intersex people can be transphobic.  Intersex adults who identify with their sex of rearing and don't want anyone to question its legitimacy can reject people of any bodily configuration who are interested in transitioning. Intersex people who want to transition can consider their need more justifiable than the need of trans people born with more normative genitalia. This is wrongheaded, wronghearted.

Just as genderqueer intersex folks get irritated by trans people who hold to highly dyadic, sex-sterotyped gender ideologies, genderqueer trans folk can find stereotypical dyadic gender presentations from intersex people very disappointing. They feel that if anyone should be enlightened about the force of gender-regressive ideology, it should be intersex people. And I can certainly understand why genderqueer trans people, suffering the slings and arrows of social bias against androgyny, would want intersex people to identify outside the gender dyad. But genderqueer trans people should have empathy for the fact that the majority of intersex people do identify with a binary gender category. Given the extraordinary pressure intersex people are under to genderconform--from the medical profession, their families, even intersex advocates, above and beyond the social pressure everyone faces--genderconforming presentations are unsurprising. And everybody's gender identity deserves respect, whether it aligns with sex of rearing, against it, or ourside the binary.

Alliances

As an intersex person who is transitioning, I see clear common cause between inter- and trans folk. Many intersex people deal with transition, and live as a bridge between the inter-cis and the nonintersex trans community. Those I've just termed the inter-cis--people with intersex conditions who identify with the sex assigned to them at birth--could gain support and community if they'd come out of the closet and identify as siblings of people who sex transition. Intersex advocates could gain the support of a large pool of trans people and work together on a general campaign for the individual right to choose to use or avoid medical intervention in sex characteristics ("My body, my sex, my right!"). Trans people could gain allies whose very existence undermines the genitals-determine-gender ideology that binds people.

There are issues to address. Intersex transphobia and trans jealousy of mythic intersex advantages in transition are both highly problematic. But our commonalities far outweigh our differences, and we should be allies.

Intersex Roadshow: A Personal Introduction

Intersex by birth, honest by choice.

I'm Cary, and my sex is neither male nor female; I'm intersexed. I was born that way. Because my nonstandard set of parts included an ovotestis, which is a gonad that's in between an ovary and a testis, I'm classified medically as a "true hermaphrodite." But doctors don't get to decide who I am.

I'll explain more about the sorts of bodies that get one classified as intersex in a later post. I'll also go into more detail about how we get treated by doctors, institutions, families, and people on the street. The simple story is this: we live in a society that acts as if there are two sexed flavors of people--male and female--but reality is more complicated and more interesting. Intersexed people are all around you, though often you'd never notice us. We live in a culture that treats intersex status as shameful, and most of us born this way have been told all our lives to hide it. I'm not hiding anymore.

I am not defective. I am not disordered.

It is a simple fact of nature that sex is not dyadic, not black-and-white, not limited to two categories. Real bodies come in a rainbow of possibilities. But our medical establishment today insists on allowing for only two, male or female. Intersex conditions are deemed "birth defects" that must be "corrected" surgically, as soon as possible--even though the surgery leaves us with scarred genitals that don't look typical and have limited or no sensation. The idea is that somehow the surgery will make us have "normal" identities as men or women, and that this is vital for everyone's wellbeing.

The power of the medical establishment is so great that what limited intersexed advocacy there is focuses on doctors. The aims of advocacy are basically two: one, to stop infant genital surgery, and two, to get access to medical resources to undo earlier medical interventions. To try to reach these goals, our advocates have been forced into bizarre postures. Again, I'll explain more in a later post, but in brief, doctors dismissed intersex advocates' calls to end infant genital surgery, saying, "What?! You want to keep us from doing surgery so these poor infants will grow up to be some third-sex intersexed freaks? Never!" To placate the doctors, these advocates said, "Oh no! We just want to delay surgery a bit, but we'd never want people to grow up to be unsexed freaks! In fact, we'll never use the name 'intersexed' again. We're just people with Disorders of Sexual Development who are a bit miffed because you cut off the parts we wanted, so please give us more surgery and hormones so we can be normal men and women living with well-managed DSDs."

Well, I am not defective. I am not disordered. I am an intersexed person. And if both doctors and people who speak in my name recoil in horror when I say that I don't indentify as a man or as a woman, too bad for them.

United we stand.

A couple of years ago, something happened to me that changed my life: I met my partner, Beta. I was doing research on embodiment in virtual worlds and was interviewing people with gendertransgressive avatars. In the course of interviewing Beta, I found myself in the presence of someone smart and appealling. . . and openly intersexed. As I've said, most intersexed people have been well-schooled in stealth, so this was a rare treat. One of the joys of having Beta in my life is how things that seemed implausible in isolation became possible in tandem. Like coming out, and being honest about my birth status, or using neutral pronouns (like the pronoun "ze" instead of "he" or "she"). Like being able to assert my masculine gender identity, my intersex sex status, and a femme flair to my style of gender expression all at once, unapologetically.

Lots of people live genderqueer lives, though it' not easy for anyone, given the gender role policing commonplace in American society. Oddly enough, though, it's particularly hard for an intersex person to step outside the confines of dyadic gender, and it wasn't until Beta entered my life and lent me hir support that I was really able to do it myself.

Don't fence me in.

Something that really frustrates me is hearing advocates tell the world that "real people with DSDs" almost always identify as male or female and conform to gender norms. They say that exploitative academics want to use the idea of intersex to subvert gender, against the wishes of "real people with DSDs." They say, "Of course we have nothing against transgendered people who don't want to go all the way and like confusing others with their odd gender presentations, but really. . . people with DSDs are usually quite happy with normal male and female labels."

I was female-assigned, female-reared. I never identified as a "real woman" and wanted out of that box, but it just seemed implausible for me to do anything about it. When you're facing not only the usual transphobia, but the voice of Intersex Authority saying you shouldn't attempt to escape the dyadic gender boxes, it's hard. All I can say is that when I finally, finally came out, it was such an extraordinary relief.

So, I'm an academic, and I do think acknowledging intersexuality presents a strong critique of dyadic gender ideology. I'm not going to keep quiet about that just because it freaks out doctors with regressive gender beliefs. I am profoundly concerned that those doctors are performing lifealtering cosmetic genital surgery on unconsenting infants, but I don't think my keeping silent and closeted helps matters.

The intersex roadshow. . .

What I think will help is just the opposite. I want to take my intersex, androgynously masculine, gendertransitive self public. I want to talk about things I've been thinking about for many years, personally and academically. I want to reach out to my intersex sibs, and to genderqueer folk, and to thoughtful, interested people of every stripe. Hence this blog . . . Hope you enjoy.