Puberty Blocker Hypocrisy

 

Here's a handy graphic you can share that summarizes the hypocrisy of the laws that now ban gender-affirming care for those under 18 in half the states. 

All of them make an exception for intersex minors.The laws claim that puberty blockers are "experimental," "unproven," and putting patients' future bone health and fertility and body image at intolerable risk? That could be considered child abuse? Why, they are perfectly fine for intersex children. They're medically necessary! Proven, effective, and in use for decades.

Oh, and the genital reconstructions that absolutely nobody is performing on trans kids? Perfectly fine for intersex ones. 

There are only two possible conclusions. One is that legislators really believe puberty blockers constitute torture and child abuse--and think it is fine to torture and abuse intersex young people. More likely is the second: that the people enacting these laws don't really believe they are protecting trans kids from medical harm. They just want to make being trans illegal, while continuing to impose unrequested sex-change procedures on intersex kids whose bodies make them uncomfortable.

The Silly Idea of Your "Real" Binary Sex

 

Today, a lot of people insist that they can tell you what your "real (binary) sex" is. Let's talk about how strange that is.

Intersex is a fact of nature, found throughout the animal kingdom and across all of human history. Today, in Western societies, being assigned a binary sex at birth is a legal requirement--you need an M or F selected on birth certificates in most countries. This is so taken-for-granted that people are often astonished to learn that this is historically and culturally strange--that most world societies have traditionally recognized more than two sexes, allowing them to recognize and provide cultural places for intersex babies, and social roles for gender-variant people. This includes, by the way, Judeo-Christian societies, up until the Middle Ages. Jewish tradition recognizes four birth sexes: female, male, both (androgyne), and neither (tumtum), and early Christians followed this tradition.

But in the Medieval period, Christian authorities decided to abandon the Jewish halachic approach. They decided that the Biblical phrase "male and female created He them" was not a poetic phrase, but a prescriptive one: God demanded binary sex. 

The problem, of course, is that intersex people continued to be born. So you find court cases and church records in which judges and priests tried to decide what to do when there was a conflict over whether an intersex person (or even animal) was living in the "correct" binary sex, or "violating the law of nature" by being a man who menstruated or a rooster who laid eggs. Parties often fought vigorously, because the fact of the matter is that an intersex person or animal cannot be fit into the category "male" or "female" by definition, and what to do about that was a perpetual issue.

Then, in the 19th century, medical doctors seized on this issue and the social fascination with nature belying human ideologies of binary sex. The field of medicine was professionalizing and gaining status. And medical practitioners realized that they could gain social respect by claiming to be able to answer questions that laypeople could not. They said laypeople were confused when they saw a person with mixed sex characteristics, and could not categorize them as male or female. But medical doctors framed themselves as having impressive skills and arcane knowledge that laypeople lacked. They could dissect a person's body after death, examine their gonads, and usually, decide that those appeared to be ovaries or testes, only in rare cases finding those organs impossible to assign a binary sex status as indeterminate ovotestes.

Nineteenth century medical doctors seized on this process, as it proved successful in generating fascination and deference from the public. They proclaimed themselves teratologists (a term that literally means "having knowledge of monsters"), and declared that where unschooled laypeople saw intersexuality in a body before their eyes, doctors could determine a person's "true sex." And to do this, they announced that it was scientific law that one's "true sex" was defined by one's gonads. A person with a penis who had ovaries they named a "female pseudohermaphrodite," and a person with vulva and internal testes, a "male pseudohermaphrodite." Only people with ovotestes so intermediate doctors could not assign them as ovaries or testes, or those with one ovary and one testis, were "true hermaphrodites"--and this was rarely the case. 

And thus, long before they developed the ability to perform sex reassignment surgeries on intersex infants, medical doctors erased intersex people through classificatory sleight of hand. And in so doing, they both increased their professional prestige, and propped up dedication to binary sex ideology in the face of its obvious factual refutation.

Then, in the 1930s, scientists discovered the "sex hormones"--testosterone, estrogen, progesterone, etc.. Gonads as anatomical organs lost their luster, as it was the hormones they produced that were the new subject of fascination. And for the next several decades, the idea that testosterone was the "essence of maleness" and estrogen the "feminine essence" was all the rage. Doctors made all sorts of strange assertions: they could "cure" an abrasive, nagging, shrewish wife with estrogen therapy! Homosexuality was caused by a hormone imbalance, as men with too little testosterone mimicked female behavior and desired a husband to dominate and penetrate them! Testosterone "causes" leadership, and high testosterone would make one a politician or CEO or general! Meanwhile, low testosterone would impede mathematical ability or the capacity to read maps!

Only it turns out that people of all sexes produce and require all of the sex steroid hormones. And that women who are housewives tending young children produce more testosterone than women who are employed outside the home in business careers. And that there are no hormonal differences between people of differing sexual orientations. Yes, testosterone causes the growth of facial and body hair, and estrogen the growth of breasts and hips. But there are endosex cis men with very low testosterone who are elite competitive athletes. As a way to determine supposed "true (binary) sex," hormones didn't cut it.

So, scientists and medical doctors dropped sex hormone levels as the way to determine the "true sex" of an intersex person. And they switched their focus instead to chromosomes--particularly, the presumption that all females have the XX genotype, and all males XY.

Now, we should note that by this point, there were doctors and scientists arguing that no single factor could determine a person's "true sex." This camp would go on to develop the language of "best sex" rather than "true sex" in choosing a binary sex assignment for intersex infants (which sounds nice enough, though the outcome was the same--by this time, forced surgical sex reassignment was presumed "necessary" by doctors across the spectrum).

But there was great appeal to framing a person's "true sex" as based on their chromosomes for medical professionals desiring to hold onto the claim that their scientific abilities made them into oracles, able to perceive and proclaim a "true binary sex" where laypeople saw a spectrum. Chromosomes cannot be seen with the naked eye, so they make an impressive divination prop. Take a cheek swab, subject it to esoteric technical tests, and mysteriously out would pop the answer: XX or XY, female or male.

In fact, the claim of a neat binary sex division in chromosomes also proved quite false. There are so many variations, including people with the genotypes XXY, XYY, XXYY, XYYY, Xo, and more. There are people who are XX/XY, having some body cells with XX chromosomes and some with XY. This "macrochimerism" is accompanied by totally normative "microchimerism" in people who have gestated. It turns out that fetuses and their gestating parents exchange genetic material, so a typical XX woman who has gestated an XY baby will have XY cells found scattered throughout her body. Then there are people who have typical-appearing male bodies who are XX, and vice versa. 

In short, whatever tool medical science devises to divide the sex spectrum into two will always fail, because sex is not a binary.

However, there are those who are intensely devoted to the ideology of binary sex. These people have made a religion of it, and indeed, in the U.S. today they are often white evangelical Christians. But it can also be a secular faith--as we can see exhibited by TERFs. These are the trans-exclusionary radical feminists who screech that sex is an inborn binary that creates predator males and victim females, and frame trans women as males in dresses who pose a sexual threat to cis women. TERF ideology holds that sex cannot be changed, and that no matter what hormone therapies or surgeries a trans woman accesses, she will always remain "truly male" due to having an XY genotype that cannot be changed. This is a position of transmisogynistic bigotry, framed as "scientific fact." (That's hardly novel--the tactic of claiming one's bias is just a statement of scientific fact proved very potent in eugenics, culminating in the Holocaust. It's morally repugnant--but it's also effective.)

TERFs like to say that they have great sympathy for intersex people. They claim that most of us are disturbed by our status, and desire nothing but to have it corrected and to keep this medical past quiet, so we can lead normal lives. This position is the exact same one taken by doctors whose imposition of unconsented-to surgeries on intersex infants intersex advocates deplore. It also allows TERFs to frame intersex people who oppose their assertion that chromosomes determine "true sex" as at best unrepresentative, and as more likely charlatans--trans people pretending to be intersex to try to excuse their "delusional mindset."

But an intersex person need not be at all unhappy with their binary birth sex assignment to be appalled by Christian fundamentalists and TERFs championing the idea that one's "true sex" is determined by chromosomes. Consider a person with CAIS (complete androgen insensitivity syndrome). She has been assigned female at birth, having been born with typical vulva. Inside, she has no uterus, and what lie in the typical position of ovaries are testes. But because her body cannot respond to testosterone, and because some of the testosterone that those testes begin releasing at puberty is naturally converted to estrogen, she has developed breasts and broad hips in the course of a typical feminizing puberty, though she does not get a menstrual period. Her birth certificate says F, she was raised as a girl, her body looks like that of an endosex female, and she identifies as a woman. But according to the TERFs, because her chromosomes are XY, she is "really" a male.

This is just like how a 19th century teratologist would approach our intersex individual. Dissecting her body after death, they'd find that her gonads were actually testes, and declare her a "male pseudohermaphrodite." 

And this is violence. Sex policing and misgendering are always violence.

The fact remains that no matter what scheme devotees of binary sex ideology dream up to try to force the nature of sex into two boxes, it will always be silly, and it will always fail. By nature, sex is a spectrum of great diversity. Our intersex bodies are real, and they are not evidence of disorder or failure, but rather of the beauty and complexity of all of the natural world. Any claims that science can determine our "true (binary) sex" deserve no more than eyerolling.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.