I’m currently reading Alice
Dreger’s book ‘Hermaphrodites and the Medical Invention of Sex’ and trying to
clarify for myself a series of questions about sexual dimorphism and social
construction claims about biological sex. The book itself is excellent and
highly readable, and surely a valuable resource for anybody who is interested
in the history of how intersex people have been treated by society (and
specifically the medical establishment) over the course of the past two
centuries. Dreger is an advocate for intersex rights, and supports the rights
and humanity of intersex people. For these reasons I would recommend the book unhesitatingly
to anyone interested in this subject. My take on it here will be quite narrow
and critical however, because I don’t agree with the strong version of the ‘sex
as a social construction’ thesis which frames the historical narrative.
Dreger is an historian who does not
question the Michel Foucault / Judith Butler inspired poststructuralist model
of inquiry, and describes the history of medical definitions of sex through the
nineteenth and twentieth century without any reference to a universal, history
and culture independent account of ‘true’ sex. In a characteristic passage she
states:
So, if we want to sort, what should we employ as the necessary
and/or sufficient traits of malehood and femalehood? What makes a person male
or a female or a hermaphrodite? This is the problem. Today my own students,
college students in history classes, sometimes in exasperation ask these
questions of me at the end of a discussion of the history of sex, as if I am
holding the ‘real’ answer from them. ‘What really is the key to being male,
female, or other?’ But, as I tell them, … the answer necessarily changes with
time, with place, with technology, and with the many serious implications –
theoretical and practical, scientific and political – of any given answer. The
answer is, in a critical sense, historical – specific to time and place. There
is no ‘back of the book’ final answer to what must count for humans as ‘truly’
male, female, or hermaphroditic, even though the decisions we make about such
boundaries have important implications. Certainly we can observe some basic and
important patterns in the bodies we call ‘male’ and the bodies we call
‘female’. And the patterns we notice depend in part on the cognitive and
material tools available at a given moment. But the development of new tools
doesn’t get us closer and closer to some final, definite answer of what it is
to be ‘truly’ male, female or hermaphroditic. Instead it only alters the parameters
of possible answers. A hundred years ago we could not point to ‘genes’ in the
way we can today, but being able to point to genes doesn’t mean that we have
found the ultimate, necessary, for-all-time answer to what it means to be of a
certain sex[i].
The theoretical model is that of a continuum or spectrum, with
more male traits on one side and female traits on the other. In the middle is a
blurry bit which gets labelled ‘intersex’ or ‘hermaphroditic’ (I’ll use the 20th
century term ‘intersex’). Because the points which define boundaries between
male, intersex and female change over time according to changing medical
definitions and theories, ‘sex’ is a socially constructed form of categorisation.
To put things very crudely, the wider and more fluctuating the blurry middle
part is, the more arbitrary and less ‘real’ sex classes such as ‘male’ and
‘female’ are. There are at least three distinct claims which typically employ the
sex as continuum model as a fundamental premise:
1. Biological sex is socially
constructed
2. Biological sex is not real
3. Biological sex is mutable
and changeable
I'll come back to claim (2) at the end of this post, but for now I will restrict my focus to the question of the nature of the continuum.
Specifically, if we accept that sex can be thought of as a continuum, how big
and how ‘blurry’ is the intersex part in the middle?
The Frequency of
Intersex Conditions
Alice Dreger’s discussion of the
complexities and pitfalls of arriving at a firm and precise percentage are
worth recounting and careful consideration. Before she gives any statistical
estimate, Dreger lists a number of reasons why ‘it is almost impossible to
provide with any confidence an overall statistic for the frequency of sexually
ambiguous births[ii]’.
Specialist medical texts offer different frequency estimates, so we don’t know
which sources to trust. The samples upon which they are based might not be
representative of the entire human population. Sometimes very rare intersex
conditions cluster in particular geographic regions, so it is hard to work
these local variations into a global statistic. Environmental factors such as
hormone treatments complicate the picture further.
More fundamental considerations
include the question of what exactly counts as an intersex condition. Some
types of intersex conditions result in very clear anatomical ambiguity, whereas
other types are less severe or less obvious. Particular conditions may or may
not manifest themselves as cases of sexual ambiguity. Should we count all of
the people with all of the various conditions, or only the cases in which sex
is difficult to determine? Dreger’s account is also centred around the idea
that the category of ‘intersex’ is culturally and historically relative:
… such a
statistic [of intersex frequency] is always necessarily culture specific. It
varies with gene pool isolation and environmental influences. It also varies
according to what, in a given culture, counts as acceptable variations of
malehood or femalehood as opposed to forms considered sexually ambiguous. And
it varies according to what opportunities there are in a given culture for
doubts to surface and be articulated on record. […] Frequency is specific to particular
cultural spaces[iii].
Nevertheless Dreger does eventually
offer us a statistical estimate:
When I am
pressed for a rough statistic, I suggest that today, in the United States,
probably about one to three in every two thousand people are born with an
anatomical conformation not common to the so called typical male or female such
that their unusual anatomies can result in confusion and disagreement about
whether they should be considered female or male or something else. Anne
Fausto-Sterling, through recent research, estimates the incidence of intersexed
births to be in the range of 1 percent, although Fausto-Sterling warns that the
figure ‘should be taken as an order of magnitude estimate rather than a precise
count.’ (In other words, the number might be closer to one in a thousand.)[iv]
Although I appreciated the reasons
for Dreger’s reluctance to state an exact figure, I found this statement to be
very odd. Was it one in a thousand or one in a hundred? It looks like Dreger
might be inclined to a more conservative figure than Fausto-Sterling, but she
does not explain why.
It turns out that Anne Fausto-Sterling
is one of the authors of the only academic study which attempts to rigorously
answer this question:
We surveyed the medical literature from 1955 to the present for
studies of the frequency of deviation from the ideal male or female. We
conclude that this frequency may be as high as 2% of live births. The frequency
of individuals receiving corrective genital surgery, however, probably runs
between 1 and 2 per 1000 live births (0.1 – 0.2%)[v]
Again, there are two estimates: a
liberal figure of 2% and a conservative estimate which differs by an order of
magnitude – quite a big gap! In a paper written before this research was
carried out, Fausto-Sterling provides an even more ambitious frequency estimate,
together with an almost lyrical evocation of the ‘sex as a continuum’ thesis:
For some time medical investigators have recognized the concept of
the intersexual body. But the standard medical literature uses the term intersex as a catch-all for three major
subgroups with some mixture of male and female characteristics: the so-called
true hermaphrodites, whom I call herms, who possess one testis and one ovary
(the sperm- and egg-producing vessels, or gonads); the male
pseudohermaphrodites (the "merms"), who have testes and some aspects
of the female genitalia but no ovaries; and the female pseudohermaphrodites
(the "ferms"), who have ovaries and some aspects of the male
genitalia but lack testes. Each of those categories is in itself complex; the percentage
of male and female characteristics, for instance, can vary enormously among
members of the same subgroup. Moreover, the inner lives of the people in each
subgroup-- their special needs
and their problems, attractions and repulsions-- have gone unexplored by science. But
on the basis of what is known about them I
suggest that the three intersexes, herm, merm and ferm, deserve to be
considered additional sexes each in its own right. Indeed, I would argue
further that sex is a vast, infinitely malleable continuum that defies the
constraints of even five categories.
Not surprisingly, it is extremely difficult to estimate the
frequency of intersexuality, much less the frequency of each of the three
additional sexes: it is not the sort of information one volunteers on a job
application. The psychologist John Money
of Johns Hopkins University, a specialist in the study of congenital
sexual-organ defects, suggests intersexuals may constitute as many as 4 percent
of births[vi].
**
Although the four percent figure
has been shown to be unsupported by the available evidence, it is hard not to
conclude that Anne Fausto Sterling is quite keen on the idea that the
percentage of intersex people is a lot bigger than people would tend to expect.
Vast infinitely malleable continuums need room to blur boundaries and break
categories, hundredths are way better than thousandths for this purpose.
All of the intersex advocacy
organisations I have looked at use Fausto-Sterling’s figures, and the OII Australia site contains a detailed list of distinct conditions with respective percentages. The most up to date quoted figure seems to be 1.7%, taken from a book written by Fausto-Sterling in 2000, which bases its figures on exactly the
same academic source I quoted from above.
The OII Australia site also refers
to an academic paper critical of Fausto-Sterling’s frequency estimate by Dr. Leonard Sax. He argues that Fausto-Sterling’s definition of intersex as
including ‘anything that deviates from the Platonic ideal of male and female
bodies’ is far too broad. His definition of what counts as intersex leads to a
radically different frequency estimate:
‘The available data
support the conclusion that human sexuality is a dichotomy, not a continuum.
More than 99.98% of humans are either male or female. If the term intersex is
to retain any clinical meaning, the use of this term should be restricted to
those conditions in which chromosomal sex is inconsistent with phenotypic sex,
or in which the phenotype is not classifiable as either male or female. The
birth of an intersex child, far from being “a fairly common phenomenon,” is
actually a rare event, occurring in fewer than 2 out of every 10,000 births[vii].’
The OII Australia site argues
against Sax’s narrow conceptualisation, and favours a broad and inclusive
category which
“…encapsulates
a range of atypical physical or anatomical sex characteristics. These share in
common their non-conformance with medical and social sex and gender norms. This
non-conformance with stereotypical standards for male and female is why
intersex differences are medicalised in the first place and, while that remains
the case, it makes sense to us to include them in a definition of intersex.
The
difference between narrow and broad definitions in medicine is somewhat
ideological. The exclusion of some diagnoses that embody atypical sex
characteristics but not others seems, at least to us, to be irrational.
Intersex people do not share the same identities, but we share common ground in
the stigmatisation of our atypical sex characteristics.”
Clearly
there is a very important question here as to whether scientific distinctions
and definitions are purely ‘ideological’ or not. Also, the suggestion here that
stigmatisation itself might be a criteria for what counts as ‘intersex’ is
surely problematic: flat chested women and men with high pitched voices may
well face stigma, that doesn’t mean that they are ‘intersex’. Another
consideration is how ethical considerations intersect with scientific
questions. Intersex people face marginalisation and stigma both because they
have bodies which do not conform to biological norms and also because such
conditions are in fact unusual. If the level of ‘unusualness’ is reduced, this
would arguably lessen the sense of marginalisation and stigma. Should we base
our definition of ‘intersex’ on social justice considerations or scientific
theories?
Putting
these complex and contentious philosophical questions to one side, what types
of specific ‘moderate’ intersex conditions are we talking about here? Leonard
Sax rejects several of the various types of intersex condition identified by
Fausto-Sterling because they do not fit his scientific definition. By far the
biggest category he objects to is that of ‘Late Onset Congenital Adrenal Hyperplasia’ (LOCAH). This single
category accounts for a massive 1.5% of Fausto-Sterling’s 1.7% figure. What is
this condition and what are its symptoms?
The broad category of Congenital Adrenal
Hyperplasia (CAH) is described by a popular internet medical site as:
…an inherited (genetic) condition causing swelling of the
adrenal glands. The condition is associated with a decrease in the blood level
of a hormone called cortisol and an increase in the level of male sex hormones
(androgens) in both sexes. Some people get a mild condition that produces no
symptoms. Others (mainly baby boys) develop a severe form that can be
life-threatening. Medical treatment to correct hormone levels is available.
Surgery to improve the appearance of unusual genitalia (in girls) is sometimes
considered.
Leonard
Sax accepts that the severe (and very rare) form of CAH is a genuine intersex
condition, but he denies that the milder version of LOCAH is an intersex
condition. To sum up his analysis and put it bluntly: all men who have LOCAH
are unambiguously male. Sometimes they experience balding. Many women who have LOCAH have no symptoms. Of
those that do, symptoms include excessive body hair, infrequent periods and
acne. A small percentage of women with LOCAH have a larger than average
clitoris. If you want details, refer to his article through the link above
(it’s technical but not that hard to understand). I checked out a couple of the
studies Sax refers to. Dreger is correct when she warns about radically
different estimates from academic sources – the papers referred to by Sax quote
a frequency of around 1 or 2 in 1000 for LOCAH, very different from the 1.5%
figure. I’m not an expert in medical science, so it is hard for me to understand
this massive discrepancy. The best explanation appears to be that there is a
fairly wide spectrum of conditions which include higher than average levels of
male hormones in females (androgens), including rare conditions like LOCAH but
also including much more common conditions such as Polycystic Ovary Syndrome (PCOS).
The
conclusion to be drawn from these observations is that there appears to be a
contemporary trend towards a much broader and more liberal definition of
intersex conditions. This trend is in conflict with a more conservative
scientific definition of intersex. Radically different frequency estimates are
a consequence of this ideological conflict.
The
fact that this sort of conflict exists is consistent with Alice Dreger’s over-arching
postmodern narrative. She convincingly describes how doctors and medical
specialists strived throughout the late nineteenth and early twentieth century
for a very narrow definition of intersex. By defining males in terms of the
presence of testicular tissue, and females in terms of ovarian tissue, the
existence of ‘hermaphrodites’ was squeezed into an almost non-existent
category. People with ‘ovotestes’ are extremely rare (0.0012% according to
Fausto-Sterling), so by defining ‘hermaphroditism’ in this way, Victorian
sensibilities could be preserved. The desire to preserve a rigid sex binary was
linked to societal gender norms and fear of homosexuality. The existence of
intersex people was a threat to the social order which needed to be contained,
so narrow scientific definitions were sought after for reasons which were not
always purely scientific.
Searching
around the internet for alternative interpretations concerning intersex, I came
across this tumblr blog which includes the most broad and liberal conception of
‘intersex’ that I could find. The authors of the blog insist that medical
authorities should not have the sole right to determine who is and who is not
intersex, and that people with PCOS are definitely intersex if they want to
self define as intersex. Crucially, the question of whether someone is intersex
or not has more to do with identification than it does with any sort of medical
description. The ideological underpinning of this blog may well be indicative
of a new historical era. Dreger’s phrase for the Victorian approach towards
intersex people was ‘The Age of the Gonads’. This blog may well go down in
history as representative of ‘The Age of Trans’.
Is
sex really a ‘continuum’? Is sex ‘real’?
We
can think of sex as a continuum, with male traits at one extreme and female
traits at the other. All people will fall within the reach of two intersecting
normal curves, the left curve representing mostly males and the right curve representing
mostly females. The intersection in the middle is the group of intersex people.
The problem for this very abstract model is the fact that biological sex can be
conceptualised across a number of distinct axes. We could look at genetic factors
such as chromosones, gonadal tissue, secondary characteristics (such as body
hair), genital morphology, hormone levels or reproductive capacity. Every
factor would produce a different sort of graph. The huge complexity of intersex
conditions would defy any attempt to provide a realistic picture with such a simplistic
model.
Professor Daphna Joel refers to a ‘3 G’ model of sex which defines sex on the basis of
genetic, gonadal and genital factors. Using this model, 99% of all people fall
into one of two categories, male and female. Males have all of these physical
features: XY chromosones, testes, prostrate and seminal vesicles, penis and
scrotum. Females have all of these features: XX chromosones, ovaries, womb and
fallopian tubes, clitoris, vagina and labia. This model is described as ‘almost
perfect dimorphism’. Intersex conditions mean that we cannot say that sex is
absolutely dimorphic. Some conditions (such as those which involve ambiguous
genitalia) are cases of unusual intermediate phenomenon. Some conditions (such
as Complete Androgen Insensitivity) involve a set of mis-matching features (XY
chromosones and testes combined with female genitalia). Joel emphasises how
incredibly unusual this almost perfect dimorphism is: we can be 99% confident
for example that a baby born with a penis will have all the other features ‘matching’
(testes and XY chromosones). There are very few natural phenomenon with this
high degree of probabilistic uniformity.
I’m
going to conclude by quoting a passage from an academic paper by Caroline New,
who argues against the idea that intersex conditions support the notion that
sex is not ‘real’:
Postmodern
writers massively exaggerate intersexuality and misrepresent sexual attributes
as continuous rather than as distributed dimorphically, despite the variations
and overlaps on any one dimension.
Do these variations mean that sexual difference is not real? Once again
postmodern feminists have higher standards than anyone else for categorisation.
Hawkesworth maintains that females and males are not ‘natural kinds’ because
there is no set of properties possessed by every member of each of these groups
(1997). From a realist point of view,
‘natural kinds’ are so called because they tell us something about the causal
structures of the world. Causally important properties are contingently clustered,
but in such a way that the presence of some properties renders the presence of
others more likely – because there are common underlying properties that tend
to maintain the clusters of features (Keil, 1989:43). Biological kinds can
never meet the essentialist criteria postmodern thinkers implicitly require
(Boyd, 1992). Biology is messy and complex, and its regularities take the form
of tendencies rather than laws. In the case of sexual difference, these
tendencies are strong, ‘the genotypic and phenotypic division of bodies into
two sexes crosses species and millenia’ (Hull, forthcoming). Sexual difference,
then, is a ‘good’ abstraction. Pace deconstructionists, it brings together
characteristics that are internally connected, and the connections in question
are substantial, not merely formal (Danermark et al 2002).
[i]
Dreger, Alice D. ‘Hermaphrodites and the Medical Invention of Sex’. Harvard
University Press,1998.
[ii]
Ibid, p.40
[iii]
Ibid, p.42
[iv]
Ibid, p.42
[v] [Melanie Blackless, Anthony Charuvastra, Amanda Derryck, Anne
Fausto-Sterling, Karl Lauzanne, Ellen Lee, 2000, How sexually dimorphic are we? Review and synthesis , in American Journal of Human Biology 04/2000;
12(2):151-166.]
[vi] Anne
Fausto-Sterling, 1993, The
Five Sexes, in The Sciences 33: 20-25.
[vii] Leonard Sax, 2002, How
common is intersex? a response to Anne Fausto-Sterling, in
Journal of Sex Research, 2002 Aug;39(3):174-8.
