Intersexuals - Should they be forced to conform?

Revenant_Threshold · January 13, 2006, 5:03pm

According to the Intersex Society of America, it is difficult to estimate how many intersexuals (people with a combination of male and female sexual characteristics) are born every year; however, by their statistics it is a significant amount. Intersexuals may be born with obvious deviations from the male/female physical norm, or secondary sexual characteristic of the apperent opposite gender may make themselves known at puberty.

The usual response to a child being born with no clear gender is to surgically alter them so that they conform to either male or female physical features (usually whichever gender they have more characteristics of). Likewise, if sexual characteristics of the opposite sex appear at puberty, surgery is used as the immediate “answer”. In the case of babies, it is obviously the parent’s choice on whether to have gender re-assignment surgery - it is also often the case when such difficulties emerge at puberty, as children’s decisions (or even sometimes their permission) is not asked nor their informed consent given - for example, this quote from an article in the Psychologist (warning, .pdf file) http://www.bps.org.uk/_publicationfiles/thepsychologist/0804intersex.pdf :

As well as the ethics of forcing a person into a gender role without their permission, there’s also the problem that surgery to remove/alter sexual characteristics can lessen or even remove all ability for sexual pleasure at all, permanently. And if that child grows up and decides that they associate more with the opposite gender - yet more surgery awaits them, to undo what has been done to them and more.

On the other hand, what other options are there?

A child could be assigned a gender, but not given surgery. Clearly though, this can also cause problems - how can you explain to a child when they’re older that they’re different from other boys/girls? And how would they be able to deal with the inevitable bullying and teasing that will occur if/when others find out about their physicality? While they still have their ability and drive for sex that is often denied to others who were operated on, what chance will they have to actually find someone who is accepting of their unique situation? (I’m not saying it’s impossible, but much rarer - especially for teenagers - to be that emotionally mature).

And then there’s another option - don’t have surgery performed, and don’t assign the child to male or female, but a third gender. Problem is, of course, that now everyone will know of their condition. A third gendered person would face many difficulties - how do they name their sexuality? Are they straight, or gay? Bi? How many new gender categories should we create for intersexuals - one for every condition? There are so many variations, we may end up with ten or more added genders (i’m not saying this is a bad thing, just more complicated and confusing for all concerned). And what about their legal status? Are they counted as which of the two genders they show more characteristics of? Are they allowed to marry a partner of their choice? How awful would be the societal stigma?

So here’s the debate. Four basic questions:

Should intersexual babies be assigned a gender (male or female) at birth, and raised as that gender?
As part of this, should they be operated on at birth to make them conform physically to that gender?
Should parents be allowed to make the decision on surgery, at birth or at puberty, that will drastically affect that child’s future?
Generally, what would you consider to be the best governmental and legal policies with regards to intersexed people, in relation to their rights and in comparison to “normal” men and women?

Anaamika · January 13, 2006, 5:34pm

Warning: That pdf contains a HUGE, colorful picture, that is not very safe for work.

Rev, dear, I’ll be back after I’ve read the article.

Revenant_Threshold · January 13, 2006, 5:38pm

Crap. Sorry about that. I suspect a helpful mod will be along to add a warning to it at some point, so thanks in advance.

davenportavenger · January 13, 2006, 5:43pm

I am against performing any non-life saving procedure on minors without their consent and full knowledge, and surgical gender assignment falls into that category. I don’t think that the fear of being teased in the locker room can compare to the medical complications if something goes wrong, or god forbid, they assign the child to the wrong gender. As with Moreno’s case, often the surgeries are not done to conform the body to the mental gender (Moreno is female), but to make the body more standard, which I think is gross. Who says that a woman needs to have a clitoris that is under so many centimeters long? Who says that she needs to have one at all? This is just more essentialist bullshit by people who think that bodies have anything to do with gender.

On the other hand, a kid generally does need to have a social gender in this society of ours, as much as I wish that wasn’t the case. If I had a child with one of these conditions I’d raise him/her/zir as the gender they most appear to be, but always realize that the child might turn out to be something different and be prepared to switch toys and change names if that is the case. All parents should have more of a lax attitude when it comes to kids and gender, not just because of intersexual people, but because it’s wrong to pigeonhole any child into a strict gender classification before they even know what they want. Eventually, the child would more than likely assign themselves, and then I would help them get through surgery if that was what they really wanted.

As for laws, I’m in favor of banning most non-necessary (and this isn’t) surgeries for children who are too young to consent or are not informed, so infant and childhood surgical assignment would be banned under that.

Anaamika · January 13, 2006, 6:00pm

Having read about half the articles (although I will continue to read it), I can safely say that I am disgusted and offended at what we do to intersex children. Non-consentual, non-informed surgery? No way. I am fully with davenportavenger. This is not a necessary surgery and needs to wait until the kid decides…and even then, we should be prepared for them feeling differently later in life.

This is like rape. Cutting something off because the doctor feels it doesn’t conform to our standards of sex and gender? I thought this was something that happened in third world countries (female genital mutilation).

Not only do I think this but this has switched me on circumcision, too. No unnecessary, life-altering surgeries on children. (But, please, don’t turn this into a circumcision debate). The parents are just going to have to suck it up and do what’s realy best for their kid, i.e., accepting them how they are and helping them instead of changing them from the start.

DSeid · January 13, 2006, 6:39pm

Actually there isn’t any current “usual response.” The issue is up for grabs and for good reasons. A good review of the current debate from the medical perspective can be found in this Pediatrics Commentary a snip of which is here. It is a conundrum.

The above comments pertain primarily, but not exclusively, to gender assignment. Of equal or greater controversy is the consideration of surgery, including whether nonlife-threatening surgery should be deferred until the child is mature enough to participate in the decision-making. A significant groundswell has been initiated by concerned intersex adult patients who are disappointed in the gender assignments designated by their doctors and/or parents when they were infants. The Intersex Society of North America (ISNA) (www.isna.org) was formed in 1993 by such patients and has been influential in drawing to the attention of the medical community that the traditional approach to diagnosing and treating intersex patients needed to be reexamined. The traditional approach has been used synonymously with the paternalistic approach. The latter refers to the John Money approach also, but conceptually the traditional/paternalistic approach is that the doctor and his associates made (make) the decision for the parents and the patient whether a particular patient was (is) to be raised as a boy or girl. In this context the parents were passive decision-makers but were expected to be activists on the stage of everyday life—activists in training and convincing the affected subject that he/she was truly a boy or girl with unfinished sexual development in utero. In the standard or traditional approach, the hypothesis was that nurture influence(s) outweighed nature influence(s) in establishing gender identity. The 2 criteria thought necessary in testing the hypothesis were that the sex of rearing needed to be established early (probably no later than 18 months) and the external genitalia had to be compatible with the sex of rearing. The potential for reproduction also was considered in the decision-making process. The possibility that imprinting of the brain occurred was not ignored by Money and his associates, but it was believed, as is still the case, that guinea pigs and other lower animals (see Meyer-Bahlberg4 for further discussion) were much more prone to testosterone imprinting of the brain than was Homo sapiens. Therefore, early surgery on the unfinished genitalia was essential to establish the influence of nurture on the intersex infant. Fifty years later, we have learned, in significant part from the members of ISNA and from other observations, that imprinting of the brain with testosterone and/or other androgens does occur to a greater extent than initially believed. This has become evident as a significant number (more than in the usual nonaffected population) of 46,XY intersex males raised as females, but whose etiology was not complete androgen insensitivity, elected to reassign themselves as males when they reached adolescence or adulthood. Not surprisingly, such individuals are disappointed, frustrated, and often angry. Thus, members of ISNA have campaigned for surgery of the ambiguous genitalia in only life-threatening situations until the patient can participate in the decision.

Much has been written condemning the traditional approach, and much has been written that no surgery be done on the genitals until the child can participate in the decision-making. Ethical and legal implications of performing early surgery in the 21st century are prominent in the news media and in medical journals. For example, Kipnis and Diamond,5 present case reports on which they base 3 recommendations: 1) that there be a general moratorium on such surgery when it is done without the consent of the patient, 2) that this moratorium not be lifted unless and until the medical profession completes comprehensive look-back studies and finds that the outcomes of past interventions have been positive, and 3) that efforts be made to undo the effects of past deceptions by physicians (“deceptions” refers to not telling the patient the complete history, physical findings, karyotype, anticipated outcome, etc). However, Meyer-Bahlberg,4 in a statesman-like, scientifically accurate rebuttal, counters the data on which these recommendations were made. Nonetheless, other reports6–8 continue to tout that surgery should not be done unless a life-threatening situation prompts such surgery. Many surgeons, psychologists, and pediatric endocrinologists believe the stance of such recommenders is extreme in that the delay will produce as many or more problems for the majority of patients as surgery in infancy creates.

Interestingly, pediatric urologists are polarized in respect to performing early surgery or delayed surgery. A plea for delayed surgery was made in 2001 by Creighton et al9 on the basis of a review of 44 adolescent patients of various etiologies including 11 with congenital adrenal hyperplasia, 11 with abnormalities with development of the cloaca and/or urogenital structure, and 12 with other causes. The average age that surgery was first performed was 8 months. All surgeries were done between 1979 and 1995. On the basis of the need for repeated surgery in most of the patients plus other poor outcome data, Creighton and colleagues concluded, "It is important that clinicians and parents understand that genital ambiguity cannot be corrected in infancy by a single procedure. For most individuals, additional treatment will be necessary in adolescence and the long-term impact of such treatment on adult sexual function is still unknown. Alizai et al,10 also from the United Kingdom, on the basis of postpubertal examination of 14 adult congenital adrenal hyperplasia patients, concluded that the results were disappointing when surgery was done early even by the hands of competent specialists. Alizai and colleagues recommended that early surgery not be done except for simple surgical procedures, and that with the presence of a high or intermediately high vagina, surgery should be delayed until after puberty.

In 2001 the British Association of Paediatric Surgeons Working Party on the Surgical Management of Children Born With Ambiguous Genitalia11 produced a statement on the current thinking about, and suggestions for, surgical practice on children with genital ambiguity. In respect to delaying surgery until the patient can consent, the UK urologists believed this policy would be too prescriptive; however, parents (all of whom must provide consent) must be made aware of the possibility that nonoperative management with psychological support for the child and family (such as recommended by the ISNA and others5–9) is an alternative to surgery. In this report the recommendation for the severely undervirilized genetic male is that the assignment of such individuals to the female gender by surgery should only be undertaken with considerable caution and after complete multidisciplinary investigation and full counseling of the parents. The second study1 by the Johns Hopkins investigators reports more favorable results than was expected by most working in this field. However, despite the equalness of outcome results of the infants assigned as male and those assigned as female in the Johns Hopkins report, my inclination, if I was the responsible physician is this situation, would be in the manner recommended by the UK group generally in favor of seeing the infant assigned in the male gender. However, I would certainly not encourage the assignment of the male sex if the infant had a very small phallus, little fusion of the labial folds, and was demonstrated to have partial androgen insensitivity. Each case must be considered individually.

kimera · January 13, 2006, 7:06pm

I don’t think you would have to explain, most of them already know. All the intersexed people I know (I haven’t known a lot to be fair) already knew they were different from other children. Boys that have had their penes removed due to botched circumcisions know that they are different than other girls from a very young age.

If the child is forced into a gender that he or she does not identify as, then he/she will be forced to “transition” later in life. Transexuals are often teased and bullied and even killed. If the child is allowed to decide for themsevles, they will normally do so at a fairly young age. If they get hormones early enough, no one will be able to tell that they weren’t born a normal male or female. The only way classmates would know is if they were forced to unrobe in front of them or they identified as male when younger and then decided that they were female during the later years. There have been children who identified as transexual whose parents supported their transition and they came out in grade school. From what I have read in those cases, their classmates don’t have a problem with them - just the parents. I am friends with a 15 year old canadian transexual who has had no problems transitioning at school. Her teachers and classmates have all been very accepting or at least, not outwardly hostile.

There are open transexuals who have partners even without surgery. My best friend is a post-op mtf who is dating a straight guy. If transexuals, generally regarded by the public as chosing thier fate, can find love, then an individual with a genuine medical condition should be able to. I do not deny that they will have harder luck than the average population, but it is not impossible. Besides, with some conditions, no one would know unless they chose to tell.

I think for the sake of the parents who will be asked “is it a girl or a boy?” that the parents should select a gender for their child but maintain an open mind and accept that the child may not agree with that gender classification.

No, never. I don’t think that parents have to right to make such a decision.

I don’t think this society will ever accept third genders. If it will, it will be a long way off. Instead, intersexed people should be treated with the legal rights of whatever sex they identify as. If they wish to develop more male or female characteristics, then they should be allowed to do so without government intervention. An intersexed person with the label “male” on their birth certificate should be allowed to marry another male. (I’m for gay marriage in general)

As for what the third sex would call themselves, I know some who identify as a third sex. They call themselves “pansexuals.” Others use the term “androphile” and “gynaecophile” and could easily come up with a term for those who love the third gender.

MEBuckner · January 13, 2006, 9:13pm

Moderator’s Note: I disabled the link; to read the article, just copy the URL and paste it into the address field of a new browser window.

Revenant_Threshold · January 13, 2006, 9:20pm

Thanks, MEBuckner, I’ll be more careful in future.