Images and Musings Available on Tumblr

Sometimes I run across images related to intersex matters that make me want to applaud, or to go hide under my bed.  I've decided to start sharing some of these pictures and my thoughts on them on Tumblr, so if that sort of thing interests you, feel free to visit The Intersex Roadshow Reports.

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.

Viewing Intersex Genitalia (Note: Explicit Artwork Included)

Disclaimer

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

Does a Picture Paint a Thousand Words?

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

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

Anatomy of an Intersex Person

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

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

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

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

What Doctors See

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

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

On Hypospadias

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

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

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

The Moral of The Post

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

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

The Intersex Peep Show

No, You Can't Look in My Pants

Since I started coming out publicly as intersex, I've been asked by some people I've barely or never met to show them a photo of exactly what I keep between my legs. This is a very odd question--consider how you'd react if you received this request from some stranger. It can be disconcerting and creepy to realize that someone you don't know is thinking about your genitalia, requesting a photograph.

So no, I don't spread my legs for strangers. And motivation doesn't matter much to me in answering requests. Some people ask because they're kinksters. Don't get me wrong--I support everyone's right to their consensual kink--but I have not consented, and they don't get to play. Other people ask because of simple intellectual curiosity, and I support intellectual curiosity too. But I am not a specimen any more than I am a porno spread. I'm a person, entitled to my dignity.

Recently somebody contacted me wanting me to describe my genitals and my surgical history so zie could feel confident I was really intersex and not some poser. And while I empathize with intersex people feeling used or misrepresented, the answer remains no, you don't get to look in my pants to perform your gatekeeping.

But How Can We Not Discuss Intersex People's Genitalia?

This is an entirely different question than asking to see my. . . jonk. You're right, it seems odd to discuss intersex status without discussing genitals. I do want to point out that we discuss male experience, female experience, and the experiences of androgynes and genderqueer folk all the time without discussing their genitals. We don't ask to verify what they've got down there before discussing their gendered lives. And what defines intersex experience isn't genitalia but the social reaction to our bits--the way our very existence seems to create a crisis for medical professionals, families, and ordinary folk. There's no need to discuss our genitalia to address that social reaction.

But. I do think we should, as a society, discuss genitalia. How they come in a wide variety of configurations, a spectrum not a binary. We need to be aware of variation, not just in the genitalia of those of us labelled intersex, but those considered unproblematically male or female. Lots of nonintersex people feel anxiety about whether their genitals are "normal," or too small, or too loose, or too asymmetrical. We should know what genitals really look like. And a picture does paint a thousand words.

What's Wrong with Pictures of Genitals

The photos and illustrations of genitals most people see are highly problematic. They do injury both to the viewer and the person being viewed. Mostly, we're exposed to two sorts of pictures: either pornographic images, or medical ones.

I'm strongly opposed to censorship, and I stand up for the right of people to produce and view porn, but most of it is terrible. I'll mention two of the reasons why: first, most porn does harm to the viewer by showing a single "idealized" vision of the human body, and secondly, it harms the models (especially the female-assigned ones) because they are viewed by our sexnegative society as whores and perverts. From an intersex position, the representations of "us" as "hermaphrodites" in most porn are actually usually photos of nonintersex male-to-female trans people financing their transitions by filling the demand for images of "chicks with dicks." In a world where sex transitions are both costly and not covered by medical insurance, and where trans people suffer profoundly from employment discrimination, I empathize with the "herm" porn models. But the fetish market that they feed gives people a very skewed perspective on the lives of intersex and trans folks, and this peep show teaches people very little about what intersex people's parts look like.

Then there are clinical medical images, of two varieties. One are the sort of illustrations we see in educational contexts. For example, buy a package of tampons or condoms, and you'll find instructional illustrations included. Intersex genitals are never pictured, but really, few people's genitals look like the images you see. The illustrations in the tampon packages are almost always hairless with tiny symmetrical labia minora--they look prepubescent, and prepubescent people don't get menstrual periods. The penises in the condom illustrations are all circumcized, erect at a high angle, and look more like a hot dog than a human. Clinical educational illustrations seem designed to make ordinary people feel anxious about their genitals, their small penises and large clitori, their veins and moles and asymmetries and hair.

Still, at least nonintersex people see illustrations that somewhat approximate their bits.

If you want to see what intersex people's genitals look like, you have to turn to another sort of medical image: the clinical photograph. And the photographs range from depressing to truly appalling. Generally they're photos of children, taken without their consent. Sometimes you can see that the child is being held down. Orifices are stretched open by adult hands, foreskins are pulled up in the jaws of forceps, and ruler scales cut into delicate skin. The photographs are utterly dehumanizing--people reduced to "disordered" genitals and treated as specimens, with as much consideration as a doctor would show a biopsied sample of a tumor. It's as much horror show as peep show. Intersex children are treated as freaks, forced to spread their legs, and hurt without their consent--and because it's done in the name of Science, it's supposed to be OK.

It's not OK.

My Complicity, My Shame

The lack of education about intersex genitals is harmful in multiple ways, and one of them is that it makes us into peepers, and collaborators in the abusive treatment of intersex children.

I grew up knowing I was genitally different, but unsure of what it might mean. By my early teens I was looking through medical journals for pictures that might tell me more. I'll post sometime on my academic research on teratology, the branch of medicine that deals with "birth defects"--suffice it to say for now that I've looked at a lot of medical images of intersex people. And I can try to justify it in terms of personal need and academic critique, but in the end, I'm complicit. Not that I've ever sent a stranger an email saying "Can you send me a photo of your privates?" But I've contributed to maintaining the market for exploitative and abusive medical photography of intersex people.

What Can Be Done?

It seems to me that there is a real need for a collection of cruelty-free, nondistorted images of intersex people's bodies, including our genitals, for people to view. I imagine that illustrations would be best. There may be people out there with various intersex conditions or "DSDs" who would be willing to be photographed by a respectful ally for a public image gallery, but I suspect most people, like myself, would be very wary of the idea. Drawings would avoid the issues of shaming or disrespectful use of our bodies. Ideally, they would be nonidealized. They could be warm rather than clinical, human rather than dehumanized.

I'm going to try my hand at it. I'll see if posting a drawing turns my blog from the intersex roadshow to the intersex peepshow--I certainly hope not. But it does seem like an important project to me.

The image in this post is a manipulation by me of a photograph provided under a Creative Commons license by just.Luc here.