Intersex: the ethics of technologically constructing gender

vgaffney's picture


           In recent years, the ethicality of medical intervention in order to normalize the appearance of intersexed individuals has been met with increasing scrutiny. Within the field of medical ethics there has been a rising concern for the consequences and implications of such appearance-altering surgeries. As much of the research on the subject suggests, the problem within the medical field stems directly from the pre-formed cultural and societal understandings of the “normal” or “true” understanding of sex and gender. The treatment of these individuals is enmeshed with cultural perspectives and thus consistently reinforces the traditional gender binary, regarding those individuals who stand outside the binary as unnatural deviants requiring medical intervention to ameliorate their defects. Perhaps the most important factor is the advent of technologically constructing gender: with this technology doctors are able to implement procedures and techniques which are aimed at maintaining the “natural” gender binary. The ethics of technologically shaping intersexed individuals is highly controversial because the argument for the individual’s well-being is invoked on both sides. Exploring three particular issues with regard to intersex—and the manner in which this condition is dealt with—will help shed light onto the complexities of the problem. The rationales that are provided for surgical intervention, followed by an examination of the consequent ethical concerns, and finally an investigation into the potential to challenge this social binarism will help to identify the serious implications of technologically shaping individuals’ gender.

            In a relatively recent New York Times article entitled, “Behavior; If Biology is Destiny, When Shouldn’t it Be?” Barron H. Lerner suggests, as far back at the 1940s and 1950s doctors had begun to regard technologically shaping gender as their obligation, adopting the ethical perspective that to shape the gender of child is to ensure a gender identity. There are two important rationales for technological intervention: medical rationales—which are predicated on physicians’ sense of obligation—and legal rationales which are deeply embedded in our cultural perspectives on gender.Within the medical community, there have been numerous doctors who have believed in viable medical reasons for altering the anatomy of intersexed individuals. In his dissertation at the University of Southern California, David Armstrong posits a number of medical imperatives for technological intervention. When treating an intersexed child doctors generally believe in an underlying sex, that is, a particular sex which is the true sex of the individual and as a result believe that there are “only two viable psychological genders” (78). As a result it is imperative that doctors use the technology available to ensure that the child grows up as a distinct sex and gender. Medical professionals consider these procedures to be supplemental in that they are merely ensuring the natural manifestation of gender (135). Additionally, doctors justify their decisions to alter the anatomy of an intersex child based on the theory of “gender plasticity at birth” (80). This understanding argues that all children—even those born with unambiguous genitalia—need to be guided, directed and reinforced to behave within the confines of his or her gender corresponding to the appropriate sex. Medical practitioners apply this argument by saying that it irrelevant whether the intersex child is assigned a male or female anatomy because their gender is plastic at birth—they need only be guided in a certain direction to ensure gender identity. Most medical professionals regard intersex as a “social and psychological emergency” which if left untreated can lead to a life of “rejection and trauma” for the child (83). Ultimately, as Armstrong writes: “our culture deals with gender ambiguities by making health care practitioners’ skills relevant to defining and resolving the problem (76)”. In this sense technology is seen as the resolution to the intersex problem; technology is used a tool to shape and uphold the present cultural standards for the gender binary.

            In addition to the medical imperatives, there are legal reasons for technologically resolving gender ambiguities. These legal reasons are, of course, shaped by the current cultural climate, and as a result merely reinforce the stigma surrounding intersex. In the same article Armstrong states: “Our society’s common sense understanding of intersex is codified, institutionalized and enforced by law” (15). In this statement Armstrong invokes the notion of “common sense”, suggesting that there is something culturally embedded and automatic in society’s understanding of gender: it is simply assigned at birth and thereby transferred to all the future important legal documents: birth certificate, driver’s license, marriage certificate, death certificate. The very fact that there are only two options—male and female—suggests that legally intersex does not even exist; the legal system as it stands simply does not acknowledge the reality of intersex and thus reinforces the gender binary, providing greater rationale for the technological shaping of intersex individuals.        

            Such surgical procedures introduce numerous ethical implications centering on three main issues: secrecy, physiological effects and psychological effects. Some of the most blatant ethical concerns arise within the context of medical ethics. As Lerner presented in her article, much of the outrage among intersexed individuals surgically altered in infancy stemmed from the fact that “their variant genitalia had been treated like a disease and ‘corrected’ secretly” (1). One of the main characteristics of this reconstructive genital surgery is that it is done when the child is an infant—and has no say—and is also encouraged by the doctors to be kept a secret from the child. The medical rationale for keeping the true nature of the child’s gender a secret is to prevent gender identity disorder. Armstrong discusses this concern in his article relating the common practice among medical practitioners to keep the reality a secret from adolescents even when they are currently undergoing surgical procedures to ameliorate their ambiguous genitalia. These individuals are not told why they are being examined and operated on leading to increased shame. Even when adolescents are told the reasons for the procedures and are enlisted consent, Armstrong notes that doctors often pressure patients by giving them the “worst possible picture” should they opt against surgery, going so far as to say it is “medically necessary” (105). Additionally, when parents are enlisted consent they are often underinformed about the condition and consequently coerced into consenting to surgery. Armstrong relates a few cases where the parents were told of a false malignancy within the sex organs. In addition to being kept in the dark about their own condition, children and adolescents are often encouraged not to tell others about their different bodies—in order to minimize psychosocial trauma—yet this approach merely increases the shame surrounding the condition. Medical practitioners, parents and psychologists must seriously examine the negative effects of such procedures and consider the reasons for subjecting intersexed individuals to these surgeries at birth.

             In addition to these medically ethical concerns, there are substantial physiological and psychological effects of these procedures. Physiologically speaking, often the treatment done when the individual is an infant is not the last, and the child must undergo additional surgeries throughout childhood and adolescence; the technological shaping of gender does not stop in infancy. As Lerner states in his article, Dr. Alice Dreger argues that surgeons “sought to convert complex psychosocial issues into simple anatomical problems that could be fixed” (2). In this sense doctors are implementing technological means in an effort to ameliorate psychological problems that in actuality are not resolved by the surgical reconstruction of anatomy. In his article, Armstrong also states the importance of taking other factors into consideration when determining the gender of an individual, such as hormones and chromosomes. As a result he argues that doctors should not operate until the individual has developed his/her own sense of gender identity. The surgeries performed on infants often lead to reduced sexual sensation and more confusion over their sexuality. Ultimately, the psychological effects of these procedures seem to suggest that the risk—psychologically, socially, and physiologically—outweighs the potential benefits of such surgeries.

            Armstrong argues that medical practice “may indeed require revision or abandonment when it becomes clear that it may be technically sound but morally suspect” (162). Ultimately, it is clear that the issues surrounding intersex individuals are social, not medical, issues and that it is morally unsound to leave the resolution of such issues up to the medical professionals. As a result, Armstrong argues that it would make the most sense to implement social reform in order to resolve the problem; there needs to be increased awareness and education in order to change the current cultural concept of the gender binary. As Armstrong mentions, the growth of advocacy groups has contributed to creating a “positive intersex identity” (129) and suggests the legal creation of an intersex gender. Although a highly controversial and complex issue, a true resolution to the problems faced by intersexual individuals rests with social change; until intersexuals are accepted as they are there will always be shame and embarrassment surrounding an intersexual identity whether or not the surgery is implemented in infancy. As the articles discussed point out, if infants undergo the surgery there are still a number of psychological and physiological issues that the child faces throughout life, but if the child does not undergo the surgery, within the current social climate, the child will still suffer from being different. Ultimately, it is clear that the current cultural understanding of gender must be changed; until intersex is accepted as a legitimate, and natural state, society is subjecting these individuals to a life of shame, depression and trauma.



Works Cited

Armstrong, David Edward. Intersex in Context: Cultural Common Sense, Medicine and                              Ethics Diss. University of Southern California, 2003. Ann Arbor: UMI, 2003

 Lerner, Barron H. “Behavior; If Biology is Destiny, When Shouldn’t it Be.” New York                                     Times 27 May 2003. Print



Anne Dalke's picture

Bodies (and papers?) in doubt

What a treat for you to get a comment and correction from one of the academics working in this area! Yeah for webpapers! Elizabeth Reis spoke @ Bryn Mawr last spring, when Bodies in Doubt had just come out, and talked afterwards with Katie and me about the intersection of our intellectual and activist work in this arena.

You've done a good review of the history of the condition and the treatment, and created a useful "window" for anyone who might want to learn more in these arenas. So my two "nudges" in response to your paper have really less to do with the content of what you're covering than the mode in which you present it.

First, you make many large "truth" claims in the paper: "exploring will help shed light,"  "rationales will help to identify," "ultimately, it is clear that the issues are social," "a true resolution rests with social change," "it is clear that the current cultural understanding of gender must be changed." In each of those phrases, who is speaking? The language seems to come from beyond self, not through a speaking subject, and certainly not from a speaking subject who is located in the world she is writing about. In other words, your paper is curiously absent your own placement in the phenomenon you describe. So my first question is where and how you locate yourself and your experiences, in relation to the material you discuss. Why (for instance) are you interested in intersexuality and its treatment?

My second "nudge" has to do with the form of your webpaper. Try, on the next assignment, to make your work more internet friendly: look over the various projects your classmates have done, and aim for a format that looks less like a paper, more like a web "event." Form signals content, and this project, which questions the very concept of "normalizing," might itself begin to play with what we think of as the "norm" for student intellectual work.


Elizabeth Reis's picture


I enjoyed your article on the ethics of intersex. As a historian, I just wanted to make one small revision. Surgically shaping bodies began even before the 1940s and 50s. In fact, the first case I've found was in the 1830s. At the turn of the twentieth century doctors were subjecting patients to various procedures whenever they could, and I think that the 20s and 30s were particularly difficult years to be found intersex because many surgeons were developing their techniques in this area and trying one thing and another on their patients. In the 50s doctors turned to children (following John Money's advice about infant plasticity, as you mention) and in the next 50 years or so physicians followed his lead. I've written a book about all of this called Bodies in Doubt: An American History of Intersex (Johns Hopkins University Press, 2009).

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