The Case Against Gender: a review of Sheila Jeffreys’ Gender Hurts

• Jeffreys, Sheila. (2014). Gender Hurts, London and New York: Routledge
• Hausman, Bernice L. (1995). Changing Sex: Transexuality, Technology and the Idea of Gender, Durham and London: Duke University Press

I shall postpone necessary preliminary remarks and dive head-first into the juicy outrageous bits. Jeffreys pulls no punches, and combines academic analysis with shocking and uncomfortable anecdotes and images. There are no ‘trigger warnings’, and her robust, matter-of-fact style will appear shocking to some readers. Under the section heading ‘Surgery for male-bodied transgenders’, we learn of the difficulties experienced by people with surgically constructed vaginas:

In one case […] the skin of the scrotum that had been used in the constructed vagina had not had electrolysis to remove the pubic hair and the hair grew inside the vagina: ‘One day I was making love and something didn’t feel right. There was this little ball of hair like a Brillo pad in my vagina.’ A surgeon pulled the hair out of him but warned it would continually grow back[i].

Gender Hurts devotes an entire chapter to the experiences of women married to men who transgender in middle age. Typically, these are heterosexual men with a fetish for cross-dressing. They tend to embrace stereotypical notions of femininity, and their practices place great strain on their wives. Jeffreys describes the experience of Helen Boyd, a women with critical sensibilities who ‘never knew exactly what feeling like a woman was supposed to mean and rejected femininity as socially constructed and constricting’:

…her husband told her he did know what it was to feel like a woman, and it was certainly not what she had ever felt. She explains: “The more I encouraged him to find an identity that felt comfortable and natural to him, the more unnatural he seemed to me. His manners changed, as did the way he used his hands. He flipped his hair and started using a new voice.” She hoped his behaviour was just a “phase” because “I felt as if I were living with Britney Spears. It was like sleeping with the enemy[ii].”

Another chapter is devoted to the issue of women’s spaces, and the morally aggressive politics of the transgender lobby to gain male access to these spaces. The Michigan Womyn’s Music Festival, a women’s only event which has been running since 1976, has been repeatedly targeted by transgender activists. In 2010 the tactics used became ‘particularly violent and aggressive’:

Camp Trans […] “vandalised the festival and threatened festival goers”. A flyer being distributed by the activists showed a rather extraordinary degree of woman hating: “A hot load from my monstrous tranny-cock embodies womanhood more than the pieces of menstrual [sic] art your transphobic cunts could ever hope to create[iii]”.

Taken together these three examples sum up Jeffreys’ case against the politics and ideology of transgenderism. She argues that this ideology and its associated practices harm trans people, women and the feminist movement. Gender non conforming children are encouraged to identify as ‘trans’ and risk major health consequences, and gay and lesbian people also suffer.  Her arguments are based around an historical account of transgenderism as a socially constructed phenomenon which grew out of medical practices relating to intersex people and an associated discourse which created the concept of ‘gender identity’. It is this historical account which I will focus on and elaborate, but before I do this I will say a few words about the political context of Gender Hurts and some of the critical comments made about this book.

The political battle between radical feminists and transgender advocates is heated and Jeffreys’ text is without doubt a weapon, a polemic directed straight at both the heart and mind of the reader. The uncompromising use of ‘pronouns of origin’ instead of those preferred by transgender people, the claim that male power is the driving force behind the politics of transgenderism and the insistence that women should create and protect female only spaces – these tenets are all articulated in both an academic and deeply personal register. No wonder then that Gender Hurts provoked a vitriolic response from offended liberals, who denounced it as a politically reactionary exercise in transphobic hate speech. Most of the reviews I read barely engaged with the arguments made in the text, and tended to cast aspersions upon the scholarly and moral integrity of the book instead of explaining why they thought Jeffreys’ ideas and concerns were wrong and unwarranted. Tim R. Johnston, for example, states that:

Jeffreys relies on a very small, controversial, and often outdated set of texts and evidence to support her arguments. She does not acknowledge the controversial or contested nature of this evidence, nor does she entertain significant and established evidence that is critical of her position. Second, the tone of the book is extremely disrespectful, and there are several places where Jeffreys engages in significant misrepresentations of transgender people, their allies, and research. These problems call into question not only the book's academic integrity, but also Jeffreys's scholarly objectivity and rigor.

In a review which is best described as apoplectic and somewhat unhinged, ‘Overland’ reviewer Lia Incognita simply refuses to engage with any of Jeffreys’ arguments on moral grounds. Because Gender Hurts commits the cardinal sin of not accepting the truth of the statement ‘transwomen are women’, it is simply impossible that any of the arguments have any merit whatsoever. The closest she gets to engaging with the text is through quoting Judith Butler, who very clearly has not read the book herself:

“If she makes use of social construction as a theory to support her view, she very badly misunderstands its terms.  In her view, a trans person is ‘constructed’ by a medical discourse and therefore is the victim of a social construct.  But this idea of social constructs does not acknowledge that all of us, as bodies, are in the active position of figuring out how to live with and against the constructions – or norms – that help to form us.  We form ourselves within the vocabularies that we did not choose, and sometimes we have to reject those vocabularies, or actively develop new ones. [...]

One problem with that view of social construction is that it suggests that what trans people feel about what their gender is, and should be, is itself ‘constructed’ and, therefore, not real.  And then the feminist police comes along to expose the construction and dispute a trans person’s sense of their lived reality.  I oppose this use of social construction absolutely, and consider it to be a false, misleading, and oppressive use of the theory.”

In order to clarify my thoughts on these objections to Gender Hurts, I carefully examined the social construction arguments made by Jeffreys’ and the texts she uses to develop her case. The most important book she refers to is Bernice L. Hausman’s Changing Sex: Transsexualism, Technology, and the Idea of Gender. I think Butler seriously misrepresents Jeffreys’ account of social construction, and I shall explain why as I outline the most important elements of the account.

Jeffreys argues that it is possible to articulate a social construction account of transgenderism along similar lines to that of homosexuality as famously described by Michel Foucault. Just as scientific theories and medical descriptions wove themselves into nineteenth century social relations to create an essentialised and naturalised category of persons (homosexuals), the twentieth century contains a distinct yet parallel story concerning the creation of transgenderism. The social identities created through these discursive processes are shaped by the over-arching imperatives of a patriarchal system of male dominance and heteronormativity:

The creation of the transgender role can be seen as a way of separating off       unacceptable gender behaviour which might threaten the system of male domination and female subordination, from correct gender behaviour, which is seen as suitable for persons of a particular biological sex. In the case of homosexuality, the effect is to shore up the idea of exclusive and natural heterosexuality; and, in the case of transgenderism, the naturalness of sex roles[iv].

Unlike homosexuality, transgenderism required the existence of particular types of specialised medical technology. Developments in endocrinology (the field of medicine relating to hormones and hormone therapy), anaesthetics and plastic surgery occurred in the first half of the twentieth century. These developments influenced the treatment of intersex people, who were now subject to medical procedures to ‘correct’ their ambiguous sex. Whereas it is most certainly appropriate to label intersex infants as ‘victims’ of medical technology, it is not at all true that transgender people were similarly passive recipients of medical treatment. Jeffreys is most definitely not guilty of the sin of denying ‘agency’ to transgender people. It is this very agency which forms a crucial plank in the social construction account:

Hausman explains that when there was public knowledge about medical advances and technological capabilities individuals could then name themselves as ‘the’ appropriate subjects of particular medical interventions, and thereby participate in the construction of themselves as patients[v].

Both Hausman and Jeffreys describe the ideological processes and changes which accompanied this construction of a ‘born in the wrong body’ subject. Hausman provides us with an acute and insightful view into the pre-requisite assumptions required for sex change medical procedures:

To advocate hormonal and surgical sex change as a therapeutic tool for those whose ‘gender identifications’ are at odds with their anatomical sex, it is necessary to believe that physiological interventions have predictable psychological effects. In order to do this, evidence of the unpredictable psychological effects of plastic surgery must be marginalised, understood as aberrant (neurotic or psychotic) reactions, or controllable through patient selection – and certainly not the norm. It is necessary to believe, further, that patient ‘happiness’ is a recognisable and realizable goal for surgeries that have no physiological indication. And, in addition, it is necessary to acknowledge a certain autonomy of the psychological realm such that the psyche is understood as the realm of stability and certainty, while the body is deemed mutable[vi].

It is worth pausing here to take in and consider Hausman’s perspective. To question the fact that people seek medical procedures which help ‘align’ their anatomy with their gender identity is currently viewed as tantamount to a fascist hate crime. Yet clearly there are a host of quite unique and questionable metaphysical ideas which make such facts possible. Usually people seek medical treatment for physical ailments, and psychological treatment for mental distress. There are of course drug treatments for people with severe mental illnesses, but these are informed by a lively debate about the relative merits of different treatment approaches. Medicalisation of psychiatric conditions is a political subject of debate when it comes to things like drug treatments for depression, but such debate is a moral taboo when it comes to gender issues. Gender identity advocates insist that there is absolutely nothing ‘pathological’ about seeking medical treatment for gender dysphoria. This moral position very effectively silences any debates about the nature and causes of gender related distress.

These metaphysical assumptions which underlie the medicalised treatment model were facilitated by the development of ‘gender’ and ‘gender identity’ as discursive entities which became progressively removed from material biological reality. This process started in the early twentieth century with the treatment of intersex infants, and reached its peak in the 1950s and 1960s with the work of John Money, Joan Hampson and John Hampson. Prior to the 1950s the word ‘gender’ was an obscure grammatical term, and was not a part of everyday parlance. The phrase ‘gender identity’ entered the world in 1964, in an academic paper written by a psychologist[vii]. Jeffreys argues that this discursive development facilitated the normalisation of the transgender subject:

Hausman argues that the ‘production of the concept of gender in Western culture’ can be analysed. All of the medical ‘interventions’ […] depended upon ‘the construction of a rhetorical system that posits a prior, gendered self necessary to justify surgical interventions[viii]’

Hausman’s account also casts the dependence the other way around, so that medical practices and gender discourse mutually support each other:

… the semiotic shift from sex to gender, from body to mind, relied on the use of plastic surgical technologies as treatments for impaired psychological functioning[ix].

Again it is worth pausing and taking stock of the implications of Hausman’s view. She is not in any sense ‘discounting’ or ‘erasing’ the lived reality of people who come to think of themselves as born in the wrong body. She is instead clarifying the historical conditions of possibility for such beliefs to exist. These historical conditions involve both medical technology and a very particular type of gender discourse. Both Jeffreys and Hausman are severely critical of the view that transgender identities can be retrospectively located throughout history and across different cultures in various types of ‘third genders’. Transgender identities are a specific product of the twentieth century.

Hausman describes how the discourse on gender shifted from a social to a private and individualistic register. ‘Gender’ was conceptualised as both a set of social roles and stereotypes, and as a private essence inside people which develops over time. Because intersex people frequently experienced great suffering when their internal sense of gender did not match their assigned social role, the medical approach was to ‘fix’ the anatomy to line up gender identity with sex. Psychologists and sexologists increasingly emphasised the notion of gender identity, rather than gender roles, and came to view gender identity as something that was fairly rigidly ‘imprinted’ on the mind in early childhood. Hausman explains the problematic consequences of this ‘imprinting’ model:

To suggest that socially constructed behaviours are imprinted, that is, established irrevocably and without flexibility, is, however, to lend tacit support to culturally hegemonic rules and expectations. The concept of imprinted behaviour suggests the idea that while there is one correct pattern (heterosexuality with its concomitant masculine or feminine gender role expression), this pattern can be wrongly imprinted. Because the notion of imprinting suggests irrevocably established behaviours, the only way to affect (or ‘cure’) the anomalous imprint – so that the subject can engage in cultural activities as a ‘normal’ person – is to alter some other aspect of the subject. In the context of intersexuality, after gender role has been imprinted, the subject’s genital morphology and hormonal makeup become targets for medical intervention. The same holds true for transsexualism and it is in this connection that transsexualism appropriated one of its strongest arguments for surgical and hormonal sex change, as transsexuals are understood to be subjects who for some reason develop the ‘wrong’ gender identity for their anatomical sex[x].

Sheila Jeffreys observes that the majority of people who argued for these sex change procedures were male, and argues that the male character of the demand for access to medical treatment is a defining feature of transgenderism. She traces the history of this demand, from famous early cases in the 1950s such as Christine Jorgensen to the ‘pioneer’ efforts of cross dresser Virginia Price in the 1960s and 1970s. Following the controversial studies of Blanchard and Bailey, she distinguishes between homosexual men who transition and heterosexual men who are motivated by autogynephilia (an erotic fetish for dressing in women’s clothing). Jeffreys argues that we should not accept the separation between gender identity and sexuality as unproblematic, and that feminists should be wary of the motives of men who transition.

Considering Butler’s criticism of Jeffreys’ view, it is true that Jeffreys supports a sort of ‘feminist policing’. Women are justified, according to Jeffreys, in rejecting the presence of male transgenders inside spaces such as toilets and changing rooms, and a part of this justification has to do with the prevalence of autogynephilia. Women are also justified to be critical of the views put forward by male transgender ‘feminists’ such as Julia Serano. She recounts the experience of Serano who wrapped a lacy white curtain around his eleven year old body like a dress, satisfying a deeply felt urge to feel ‘feminine’. Noting that his experience is “unlikely to have been shared by many females”, Jeffreys ruthlessly exposes Serano’s efforts to “reinvent ‘feminism’ to fit his erotic interests[xi]”. What is at stake here is not the ‘reality’ of social constructions, but rather the male power and patriarchal structuring of sexuality which informs the undenied reality of those same constructions.

*           *           *

Sheila Jeffreys’ forthright and uncompromising feminist stance is tempered somewhat by her admission in the introduction that most of the literature on the transgender phenomenon is celebratory rather than critical, and that she had to read ‘against the grain’ in order to develop her account. Relying in part on the burgeoning scene of radical feminist bloggers critical of the current political climate surrounding transgender issues, Gender Hurts is best viewed as hybrid of academic theory and political polemic. Coming in at under 200 pages, it is a ‘monograph’ which left me dissatisfied, not because of its critical sensibility but because of its brevity. There may well be holes in Jeffreys’ arguments and shortcomings in her account, but Gender Hurts deserves considered recognition and engagement, not abuse and dismissal.

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[i] Jeffreys, Sheila. (2014). Gender Hurts, London and New York: Routledge, p.70

[ii] Ibid. p.93

[iii] Ibid.p.168

[iv] Ibid. p.17

[v] Ibid. p.21

[vi] Hausman, Bernice L. (1995). Changing Sex: Transexuality, Technology and the Idea of Gender, Durham and London: Duke University Press, p.63

[vii] Robert Stoller, ‘A Contribution to the Study of Gender Identity’, Journal of the American Medical Association 45 (1964): 220 – 26

[viii] Ibid. p.27

[ix] Ibid. p68

[x] Ibid. p.101

[xi] Ibid. p. 50

Transplaining Spin: Fact-checking the liberal reaction to Ask Me First

The Spinoff news site has recently published two articles in response to the Family First ‘Ask Me First’ campaign.  Laura, a student, has expressed concern about Marlborough Girls College's decision to allow a male transgender student use of the female toilet facilities. Supported by her mother and the conservative lobby group Family First, she appeared recently in a Family First video speaking out against the school’s decision and the lack of consultation with students and families. Both articles strongly condemn Laura's stance, and paint her actions as a part of a bullying transphobic campaign against a powerless and vulnerable trans student. They both claim that there are no safety concerns for the female students, whereas there are major safety concerns for the trans student. 

Is it true that the safety concerns lie squarely on the side of the trans student, and that people who question this narrative are transphobic bullies? Is it true that the trans student is relatively powerless and deserves more moral consideration than students such as Laura?

The first Spinoff article, written by Television editor Alex Casey with a palpable sense of delicious moral outrage, denies the claim that there was no consultation process. She interviews transactivist Lexie Matheson, who paints a rosy picture of ‘unity’ at the school, and claims that the ‘school consulted widely, they consulted the community, they consulted the students and the student LGBT groups, I was able to talk to most kids and see the students in her classroom.’ He goes on to categorically state:

Everybody was asked first. The school was fantastic in terms of talking to the community, sending emails and newsletters out and talking to anyone with concerns. Many people did came to me with concerns about how it would affect them. The answer, of course, is that it doesn’t affect you at all.

This directly contradicts the account given by Laura and her mother. From the recent Herald article on February 22nd:

Laura's mother says the school's claims that it considered the rights of all its students before making the decision are "really incorrect".

"They have not respected the value of the girls' vulnerability. They haven't respected their thoughts on the matter. There's over 600 girls. They also have a right to have a voice.

"I think as a parent, we should've got together in the school itself before it all happened. Why didn't they ask us what we wanted to do?"

Laura adds that while she has nothing against the transgender student involved in the stoush, she takes issue with the school's lack of consideration of her views.

"[The school] never asked me my opinion. They never respected my rights. Nobody asked me first."

So which version of events is true? Were the parents and students asked about the decision to allow a male student to use the girls’ facilities? Was there a warm, loving glow of tolerance which enveloped the entire school in support of the transgender student, Stephani Rose Muollo-Gray? Were the only exceptions to this enlightened and harmonious community small pockets of close-minded fundamentalist Christian bigots, hatefully opposed to transgender bathroom rights?

If you read Muollo-Gray’s statement which accompanied his petition to allow his use of female facilities from June last year, a very different picture emerges. He states that he started off using the female toilets, but was challenged by a teacher for doing this and subsequently had a series of meetings with the principal about the issue. The principal had originally made it a condition that Muollo-Gray should use the unisex toilets provided by the school, but Muollo-Gray had no recollection of making this agreement. The statement makes it very clear that there was a lengthy process of debate and discussion, and that the school authorities were initially opposed to Muollo-Gray’s demand:

Several other meetings occurred with very little progress. They kept trying to tell me that I couldn’t use the girls’ bathrooms because it was all about everyone’s comfort and safety, as though anyone was at risk from me just trying to use the bathroom. The one idea that they kept using as an excuse as to why I could only use the few gender neutral or male bathrooms in the school was that it would make some students uncomfortable, and that they would complain and parents would become involved.

The petition gained 6,889 supporters and the story was widely reported in the local and national media. The school soon changed its policy and Muollo-Gray was allowed to use the female facilities. There is no evidence that I could find of any sort of consultation process or vote about the issue. The most plausible story is that the school changed its policy because of the media spotlight and the pressure of the lobby groups in support of Muollo-Gray.

A second claim made by both of the articles is that excluding Muollo-Gray from female facilities would compromise his safety at the school.

Lexie Matheson states: “The primary concern is safety and feeling validated and authentic in yourself. … There is new research coming out that often young transgender women often have more bladder infections than the general population because we hold on for too long. We wait until there’s nobody around and then we go to the bathroom, and that’s really unhealthy and really unsafe.” 

In the second article, Scout Barbour Evans states that: “…the Youth ’12 report – a report on the wellbeing of transgender youth in Aotearoa – has shown that 53.5% of trans youth are worried for their own safety at school. 17.6% of them are bullied at school at least weekly, and 19.8% of trans young people had attempted suicide in the last year. These are really, really alarming statistics. …everyone is focused on this theoretical, abstract debate about whether or not transgender people should be allowed to pee outside of their own homes, while our transgender rangatahi are suffering in a real, tangible way. We know from seeing the Safe Schools and marriage equality plebiscite debacle in Australia that when this sort of bullying happens by media, the overall wellbeing of our LGBTQ rangatahi goes down.”

Both Matheson and Barbour Evans speak very generally, but appear to be saying that without access to female facilities, Muollo-Gray would be at greater risk of suffering bladder infections, bullying or suicide. Again, it’s very interesting to compare these claims with Muollo-Gray’s petition statement:

That aside what I want to get across is how blatantly transphobic the school has been against me and how upsetting this whole situation has been. There is no need to worry about other students safety in this situation. It is me who has been forced to stop using certain bathrooms; interrupting my learning and my school day. This whole situation has ended in me being told I can use the gender neutral bathrooms that are available, and that the school is looking to add more. But right now there are only four, and these are at the outskirts of the school. As a girl I want to and should be able to use the girls bathrooms. Why spend money on making bathrooms for me to be segregated and out of sight of others when I can just go in the girls’ bathroom free of charge? In the end it will be taxpayers forking out for this schools transphobia.

The sentence which refers to ‘segregation’ is quite misleading, according to this article several of the previously female only facilities had been converted into unisex facilities. Yet Muollo-Gray’s explanation is still far more honest and grounded in reality than either of the hysterical Spinoff accounts. What is at stake here is hurt feelings, the inconvenience of having to walk a bit further than other students to access the toilet and the horrendous possibility that the taxpayer would have to fork out precious funds to make more unisex toilets. The most central reason is very clearly Muollo-Gray’s presumed right to feel ‘validated and authentic’. Being excluded from female only spaces is threatening to his psychological sense of ‘gender identity’.

The second Spinoff article is titled ‘Teaching love: How to support your children through questions about gender identity’. Full of love for the gender non-confriming and gender diverse children of Aoteroa, Barbour Evans’ love does not extend to embrace those unhappy with gender identity ideology:

We’ve seen “Laura” prodded into complaining by her (IMHO) overbearing, bullying mother who raised a child to believe that transgender people are subhuman in some way. We haven’t heard anything from the student herself – a teenage girl with feelings and rights who does not deserve this bullying from her peers."

I don’t know Laura or her mother, but from watching the ‘Ask Me First’ video, it certainly is not clear that either of them view transgender people as being ‘subhuman’. Laura’s mother refers to the ‘vulnerability’ of teenage girls, and insists that males and females are ‘built differently’ and therefore need private spaces. Laura talks about the ‘stressful and embarassing’ time girls go through during puberty, and their increased need for privacy. She says that younger girls with a history of abuse or trauma would be particularly sensitive and ‘triggered’ by the presence of a male inside toilet facilities. Both Laura and her mother also express concern for the precedent set by this example, as it opens up the possibility of males using ‘gender identity’ access to female spaces for exploitative or abusive purposes.

None of these concerns require adherence to religious beliefs. It may be that some fundamentalist Christian people share these concerns, but that fact in itself does not invalidate them. Transactivists such as Barbour Evans and Matheson will invariably focus upon the supposed prejudice involved with the concern about potential abuse, and will insist that there is no evidence of any trans person ever harming anyone at any time. Unfortunately they are wrong about this, and there is considerable evidence that transgender males commit violence against women at about the same frequency as the male population as a whole. Making this observation, and raising the issue of male violence and the need for female only spaces is not ‘transphobic’ any more than it is ‘man hating’.

Perhaps the most strikingly false statement is the second part of Barbour Evans quote above, the suggestion that Muollo-Gray’s voice has been completely absent from this affair. Teenage students as a rule have very little say over how their schools are run. There are token gestures such as student representatives on Boards of Trustees, but the reality for most teenage kids is that of more or less complete powerlessness. They are compelled to wear uniforms, attend classes, meet various behaviour requirements and so on. Muollo-Gray’s influence over decisions made by the Marlborough school has been massive. The petition, the media exposure and the trans lobby combined to effectively make him more powerful than the school principal.

Psychological distress is an elusive thing to measure, but in this case the apparent harms suffered by Muollo-Gray’s gender identity were counted as being far more weighty and significant by the school than any of the discomforts or fears held by students such as Laura. Questioning the liberal orthodoxies of liberal Spinoff-doctors is an unpopular activity, but there is a compelling feminist case for doing so.

[For another left/feminist take on the Ask Me First story, check out Renee Gerlich's piece]

The Intersex Continuum

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 20^th 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).

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[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.