Sunday, November 21, 2010

Intersex and the Natural Desire for Sexual Identity

In my course "Biopolitics and Human Nature," we have had a lively discussion of Anne Fausto-Sterling's essay on "The Five Sexes." That there might be more than two sexes appears to deny my claim that human beings naturally desire to identity themselves as male or female. But in a previous post, I responded by indicating that even as I stress the dualism of sexual identity as male or female, I recognize the variation from this strict bipolarity--hermaphrodites, who combine both sexes, or those who cross from one to the other.

In that earlier post, I noted that Aristotle recognized this in his biological works. In one sense, he reasoned, hermaphrodites are "contrary to nature," because they deviate from what naturally happens "for the most part." In other sense, however, hermaphrodites are "natural," because they arise from natural causes.

Deciding how to handle those cases that deviate from the central tendency of sexual bipolarity is a matter of cultural tradition and prudential judgment. But the fact that biological nature gives us such exceptional cases should not obscure the fact that the central tendency of nature is to clearly distinguish male and female.

Since the original publication of Fausto-Sterling's article in 1993, there has been a vigorous debate over the medical treatment of intersexuality. Intersexual individuals are those whose sexual development has deviated in some way from that of a typical male or typical female. This includes various disorders of sexual development that create anomalies in the sex chromosomes, the gonads, the reproductive ducts, and the genitalia.

For example, those with Complete Androgen Insensitivity Syndrome (CAIS) show at birth a disjunction of internal and external sex anatomy. In the womb, a male fetus with XY chromosomes develops testes that secrete testosterone, which then usually has a masculinizing effect on the body and brain of the developing fetus. But those with CAIS have a molecular disorder that causes the cells of their body to be insensitive to testosterone. Consequently, an XY male might look like a girl from birth. Other disorders can produce a child having both an ovary and a testis.

For some time, it was common for many doctors in North America and Europe to advise the parents of intersexual children that genital surgery and hormonal treatments were necessary to assign children clearly to either a male or a female gender. Babies with penises considered too short for a male would be assigned a female gender identity. Babies with clitorises considered too long for a female would be assigned a female gender identity, but the clitoris would be shortened or cut off.

This medical approach was promoted in the 1950s by John Money and others at Johns Hopkins University. Arguing for an "optimum gender of rearing" model, they claimed that "gender" was socially constructed as opposed to biological "sex." Consequently, parents should decide to rear their child as a boy or a girl, and this social construction of gender could then be supported by medical procedures (surgery and hormonal treatment) that would design the body of the child to conform to the socially constructed gender identity. Many feminists adopted this model, because they liked the idea that gender was socially constructed and thus malleable, and so biological sex could be manipulated to serve the socially constructed gender identity.

But, then, in the 1990s, some people with intersex began to challenge this model by publicizing its harmful effects. In many cases, doctors and parents had lied to them, and they did not discover until they reached puberty or adulthood what had happened to them. Some of them were so uncomfortable with the sexual identity they had been given that they wanted to change to the other sex. Many of them suffered a loss of sexual pleasure that impeded their desires for sexual mating and conjugal bonding.

This led to an intersex rights movement. The history and arguments associated with this movement are surveyed at the website for the Intersex Society of North America (ISNA). The people in this movement argue that parents and doctors should tell the truth to their children about their intersex condition, and that there should be no medical intervention (such as surgery or hormonal treatments) except in cases where this is necessary for the physical health of the child. Then, when the child is old enough to decide, the child can decide whether to have medical treatments to support whatever sexual identity the child finds most comfortable.

There are some points of disagreement in the intersex rights movement. Fausto-Sterling argues that cultural attitudes should be changed so that we accept a multiplicity of sexual identities beyond the two-sex system of male or female. Against this, ISNA recommends that the cultural tradition of male-female bipolarity is so strong, and so deeply rooted in the biological propensity to create males and females, that parents and doctors should assign children to one sex or the other based on their best judgments as to which sexual identity will fit the child over the whole life span. They concede that mistakes are unavoidable: sometimes children raised as one sex will grow up to discover--perhaps at puberty--that this is not what they want, and then they can choose to change. But parents and doctors can allow for this freedom for children to decide for themselves by fully informing them as to what has happened to them, and by refraining from any medical interventions during their infancy that children might later want to reverse.

I agree with the ISNA's position. And I draw three lessons from this.

First, the gender/sex dichotomy is false. There is no sharp separation between culturally-constructed gender and biological sex. The cultural traditions of rearing boys as boys and girls as girls are certainly crucial factors in shaping our sexual identity. But human culture is constrained by human nature, so that the cultural assignment of sexual identity fails when it contradicts an individual's biological propensities. Parents and doctors must exercise prudential judgment in deciding the sexual identity of a newborn based upon their predictions of what will be most satisfying for the child as shaped by both natural propensities and cultural learning.

Second, a Platonic moral cosmology cannot account for sexual identity as an individualized human good. Many moral and political philosophers assume that the human good is determined by some eternal normativity as set by a cosmic standard of the good--cosmic God, cosmic Nature, or Cosmic reason. But this moral cosmology cannot handle the variability of the human good that comes from sexual identity. If there is an Idea of the Good that applies universally to all rational beings, does this mean that the human good is sexless? If so, doesn't this deny the empirical reality of the human good in sexual identity, in our experience that what is good for us varies according to our identity as men, women, or something in between? As a biologist, Aristotle could recognize the individual variability of the human good coming from the variability of sexual identity, but Plato could not. While many moral philosophers have followed the Platonic tradition, the recent emergence of Darwinian moral psychology supports a renewal of the Aristotelian tradition of empirical ethics.

Third, a Darwinian liberalism offers the best way to handle the moral and legal issues of sexual identity. We can recognize that by nature most human beings will be born as clearly male or female, and that sexual identity will be nurtured through parental care and cultural traditions. But we can also recognize that a few human beings will be born sexually ambiguous, and in this case, we will have to rely on parental judgment and civil society to decide the best assignment of sexual identity. The final standard will be what is most satisfying for children as they grow up and reach the age when they can decide for themselves whether their parents have made the right decision, or whether they want to change their sexual identity. The continuing debate over the treatment of intersex people illustrates how the spontaneous order of civil society generates moral standards of the human good shaped by human nature, human culture, and human judgment.

Another lesson that might be drawn from the experience of intersex people is how sexual identity depends on whether one has a "female brain" or a "male brain," which denies the idea of the "unisex brain." Some previous posts on this can be found here, here, here, and here.


Jo said...

Hello Larry
This is an interesting perspective - and mainly well targeted.

I'm continually bemused by the way The ISNA still influences perceptions in the US.

The ISNA is, of course, no more. Although it left its presence on the internet the society disbanded in 2006 and re constituted itself as the Accord Alliance.

In its reconstituted guise it negotiated what is now known as the Chicago Consensus - a set of guidelines which permitted ongoing surgical interventions.

The Accord Alliance is now run solely by non-Intersex people and to our knowledge has no Intersex board members.

Pediatric gender assignments and a raft of other totally unnecessary cosmetic genital surgeries are still the norm in mainstream medical practice.

Since 2006 they are considered justified by resort to the aforementioned Chicago Consensus - as negotiated by the ISNA/Accord Alliance!


Anonymous said...

This medical approach was promoted in the 1950s by John Money and others at Johns Hopkins University. Arguing for an "optimum gender of rearing" model, they claimed that "gender" was socially constructed as opposed to biological "sex."

It's funny to see such a glaring example of pre-PC PC-like thinking as far back as the 50s.