Gender reassignment at birth may be wrong choice

[Guest guest]

sexpolice

 

The biology of sex is being hotly debated, as parents, doctors and

researchers reevaluate what it means to be male and female.

http://archive.salon.com/health/feature/1999/04/05/sex_police/index.html

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By Sally Lehrman

 

 

April 5, 1999 |Patrick took a long time in coming -- two weeks in the birth

canal -- but the moment he arrived, nurses bundled him up and rushed him out

of the delivery room. The Jacksonville, Fla., hospital cloistered the

eight-pound, 20 1/2-inch baby in a back section of the intensive care unit

and drew the curtains. One doctor after another went to visit. The infant

had a well-defined penis, but with an opening at the base, not the tip.

There was just one testicle, though it was producing plenty of testosterone.

In most of his cells, the baby had no Y chromosome, the one that contains

the genetic instructions for the body to develop as a male. The doctors

assured the adoptive mother, Helena Harmon-Smith, that Patrick was a girl.

They would remove the offending appendages right away.

 

But Harmon-Smith had seen Patrick have an erection. Actually, several.

" You're not cutting off anything that's working, " she protested. The

authorities checked the infant's internal organs and still insisted this

baby would be better off as a girl. His mother refused. More tests. After 11

days, 20 doctors filed into a hospital conference room and solemnly

announced that they would allow the family to raise Patrick as a boy. " We

put him in a little tux and took him home, " Harmon-Smith says.

 

Two and a half months later, Patrick's doctor warned his mother that the

boy's testicle, really an ovotestis that also contained some ovarian tissue,

was probably malignant. It should be removed -- like the one already taken

from his abdomen. His mother finally agreed to a biopsy, just in case. When

the surgeon returned from the operating room, he said the gonad was

diseased. He had cut it off.

 

Harmon-Smith pestered the doctor for the pathology report for more than a

month. Once she got it, " the first thing I read was 'normal, healthy

testicle.' My heart stopped. I just cried, " she says. Five years old March

24 and in the first grade, Patrick will never be able to produce semen.

 

" My son is now a non-functioning eunuch. Before, he was a functioning male, "

Harmon-Smith says. " I don't think the doctor cared. His reasoning was that

this was a hermaphrodite, so everything should be removed. "

 

Quietly and in near secrecy, pediatric urologists and other specialists

decide what are the minimum qualifications for manhood, correcting any

babies with ambiguous genitalia -- known as " intersexed " -- before their

births are announced to the world. Under the urgent conditions of a medical

emergency, they decide whether a smallish appendage is a proto-penis or a

maxi-clitoris, and perform the surgery to make it so -- sometimes without

even telling the parents the truth about their child, and rarely revealing

anything to the patient as he or she grows up. Guiding the doctors' work is

a commonly accepted theory, pioneered in 1955 by Johns Hopkins University

sexologist John Money, that infants are psychosexually neutral at birth. If

a surgeon sculpts a baby's undersized, oversized or otherwise confusing

genitals to match a sex label within a few months of birth, normal

psychosexual development will follow.

 

But evidence is building that sexual identity is not so easy to manage or

mold. New studies in human development are demonstrating that the biological

division between male and female isn't clear-cut or even stable. The simple

presence of a Y chromosome -- considered by many people to be as

male-identifying as a six-pack of Bud and a 4-by-4 Dodge Ram -- isn't

necessarily enough to make a man. And frilly dresses adorning a body shaped

to be female can't always contain the guy hidden inside.

 

The questions aren't limited to hospital birthing rooms. From sports arenas

to geneticists' labs, experts are struggling to find new ways to define and

describe the biology of sex. And some members of the medical establishment

are beginning to question whether intersex surgeries make sense in infancy,

before the child has a chance to reach puberty, develop his or her own sense

of identity and give consent. Later this month, academic surgeons and

pediatric urologists meet in Dallas to thrash out the psychological,

hormonal, surgical and practical issues of intersex treatment. Their debates

are likely to get hot.

 

 

 

Since the 1960s, most doctors confronted with a baby like Patrick would

likely excise his penis and testicle shortly after birth and call him a

girl. If he had a Y chromosome, they might keep the penis but rebuild the

urethra to reach the organ's tip. If he had two XX chromosomes like most

girls, but an extra-large clitoris that could be mistaken for a penis,

they'd trim it back. Or if he had the right chromosomes but a very small

penis, off it would go. The surgeons were certain that life without the

appropriate genitals would be impossible, and as recently as last year, an

article in Pediatric Nursing suggested that doctors ought to consider it

child abuse if the parents refused genital remodeling.

 

Katherine Rossiter, the pediatric nurse practitioner who wrote the article

in the January-February 1998 nursing journal, argues that intersex activists

represent only a minority, albeit a vocal one, and that allowing a baby with

a tiny penis and no testicles to grow up as a boy, rather than surgically

reassigning him as a girl, might harm him beyond repair. But she admits that

" listening to what real people say and their arguments " has broken down some

of her conviction. " I've become muddy mishmash in my thinking, " she says.

 

The medical literature and the opinions of specialists are increasingly

divided. " In some cases it's led to a human tragedy -- it might have been

better not to reassign the sex of this particular child. But there are cases

where it's clearly right to reassign, " says Raymond Hintz, an

endocrinologist and professor of pediatrics at Stanford University. " It's

sometimes justified, but it's not something you do lightly. "

 

William Cromie, a Chicago pediatric urologist who serves as secretary and

treasurer of the Society for Pediatric Urology, stresses that proper

treatment relies on the carefully considered opinions of parents along with

ethicists, endocrinologists, pediatricians and other specialists. As many as

30 conditions may lead to a child being considered intersexed. " It's not an

arbitrary, capricious decision by one person, " he says. " You try to make the

very best decision -- it's usually ground over by a lot of people who are

very thoughtful. This is an area that's immensely complex. And lay people

just plain and simple don't understand it. "

 

However well-meaning, though, doctors who perform intersex surgery employ a

very finite tool in making their decision. The first measure of manhood is a

ruler: If a penis is less than one inch (2.5 centimeters) at birth, it

doesn't count. And if it's more than three-eighths of an inch (0.9

centimeters) long, it can't qualify as a clitoris either. Any appendage that

falls in the middle must be fixed. Then there's the question of the urethral

opening, which must be in the right place -- men don't pee sitting down. A

curving penis must also be corrected.

 

For a boy to be a boy, he ought to have two testicles just below a straight

penis, and only one opening down there. If the genitals fall short, a

pediatric urologist will almost always assign the infant a female gender,

remove anything protruding too far and prescribe estrogen at puberty. A

talented surgeon can construct a vagina using a piece of the bowel, although

the woman who owns it will never experience any sensation inside.

 

Hale Hawbecker narrowly escaped such a prognosis. When he was born in 1960,

his doctors, aghast at his small, perfectly formed penis and internal

testicles, wanted to reassign him female. His parents refused, not

comprehending the doctors' distress. " It's kind of a strict club in this

country to be a man, with very rigid rules to qualify, " says Hawbecker, now

a Washington attorney who is developing a legal challenge to infant intersex

surgeries in his spare time. " It doesn't matter if you're XY. If your penis

is too small, you lose it. "

 

Hawbecker says his penis size and absent testicles, removed in childhood,

don’t hurt his ability to love and make love to his wife. " I very happily

engage in sex whenever I can. You have to be creative, and not so focused on

genitals, " he says. As for his own pleasure, " My penis does everything you'd

expect a penis to do -- it's just small. "

 

Hawbecker says he thinks like a man; with his clothes on, he looks typically

male too. And yet, he says, " I guess I've never really felt like I fell

neatly into the camp of guys. I love to cook. I love to take care of things

around the house. I hate the Three Stooges and I don't like football. "

Often, he thinks about the female he might have become; where she'd be right

now. " I think she'd be OK. I could've done 'girl' too. I could be happy that

way, too. That's what's mind-boggling. "

 

Medical literature says that about one in 2,000 babies is born like

Hawbecker or Harmon-Smith, with uncommon variations of genitals and gonads,

or sex-conditioning hormones that don't match sexual organs. About one in

1,000 women has three X chromosomes instead of the usual two; some people

have had as many as four X chromosomes -- plus two Ys. Some women have

facial hair, some men don't. Breast size, voice timbre and body structure,

all generally accepted cues, also can contradict chromosomal identity.

 

" The basic story is, it isn't simple, " says Alison Jolly, a Princeton

evolutionary biologist who studies ringtail lemurs in Madagascar. " It's all

just more complicated than people will admit. " In the first few weeks of

life every human embryo develops the equipment for both sexes, the

foundations for both ovaries and testes. At about eight weeks, a chemical

chain of events stimulates one set to disintegrate. One week later, the

external genitalia begin to form -- and usually, to match what's left

inside.

 

All this seems to be triggered by a spot on the Y chromosome called SRY, for

" sex-determining region, Y chromosome, " that scientists have dubbed the

" master switch. " Throw it, they say, and a chain of events run mostly by

genes on the X chromosome leads to the development of testes and the

production of male hormones. Without SRY, females continue along what

molecular biologists have dubbed the " default " pathway. In February,

however, researchers reported the first evidence that an active signal

stimulates female development, too.

 

Of course, there's a lot more going on as well -- much of it still not even

vaguely understood. A wash of hormones primes the brain for one sex or

another, though not always the same as the one indicated by genitalia at

birth. Jolly suggests looking at sex as statistical -- a compendium of

characteristics that, when plotted on a graph, looks like a couple of camel

humps. One set of features tends to be viewed as male and the other female.

The section in between is as normal as the outlying regions in the land of

" super-macho " and " super-fem. "

 

From classical antiquity through the Renaissance, anatomists thought there

was just one sex, and it was male. Female bodies simply mirrored the male

reproductive organs -- with the vagina an inverted penis; the ovaries,

interior testicles. During the 18th century, the idea of two separate sexes

took hold. Then in 1993, Anne Fausto-Sterling, a well-regarded biologist and

feminist studies theorist at Brown University, raised a ruckus when she

proposed that male and female were not enough. In a tongue-in-cheek

proposal, she recommended five categories in all.

 

Some people seized upon the idea as a revelation finally explaining their

own bodies. Others felt the thesis went too far. Fausto-Sterling says her

readers were taking her too literally. She has abandoned the proposal --

which at root simply challenged people to think differently about sex -- and

now wants to eliminate the term from our vocabulary. " There is no sex;

there's gender, " Fausto-Sterling says.

 

Fausto-Sterling argues that scientific discoveries about the ways our bodies

work employ cultural understandings and, as in the male " master switch " and

female " default pathway, " the language of existing social models. Whenever

faced with a lack of clarity, surgeons get out the ruler and make a choice.

" There's a set of decisions by which we're going to socially agree what is a

penis. How we organize the continuous variability that nature offers us is

what gender is about, " Fausto-Sterling says. " What we call the truth of the

body is also a cultural view of the body through a scientific lens. "

 

Both the scientific and social interpretations are increasingly complicated

and controversial. The International Olympic Committee has found itself at

the center of the uncertainty. The first shock came when Hermann Ratjen, who

ran as Dora Ratjen for Germany in the 1930s, confessed in 1957 that he had

disguised himself at the request of the Nazi Youth Movement. So in 1966, as

the opportunities for women to compete expanded rapidly, a panel of judges

began checking female athletes for vaginal openings, overlarge clitorises, a

penis or testicles. By 1968, chromosome testing replaced these " nude

parades, " and in 1992, a more sophisticated instrument to hunt for the SRY

gene was adopted. But as the technology advanced, so did the confusion.

 

Five women out of 2,406 tested " male " in the 1992 Barcelona Olympics. Eight

women in the 1996 Atlanta games didn't pass as females. In February, the

Athletes' Commission of the International Olympics Committee urged its

parent organization to do away with sex analysis entirely and rely instead

on observed urination during drug testing to pinpoint any likely imposters.

 

Anatomy, gonads, hormones, genes, rearing, identity and even the

presumptions of others all play into a person's sex. " To select only one,

the genetic sex, out of a large number of sex-determining factors and

analyze for that one is scientifically incorrect, " says Arne Ljungqvist,

head of the International Amateur Athletics Federation doping commission.

 

Both women and men in sports have begun to accept a broader definition of

what a " woman " is, accepting those with chromosomal variations and sometimes

even testes. Intersex activists hope pediatric specialists also will quit

worrying about what those jock straps contain -- and indeed, some already

have.

 

William Reiner, who started out as a urologic surgeon, went back to school

after witnessing the misery of children living with the results of

sex-correction surgery. Now a child psychiatrist at Johns Hopkins

University, he says the most important sex organ is the brain. Reiner

doesn't buy any theories about a range in biological sex; in fact he thinks

it's quite binary. All the more reason to step back from aggressive

enforcement, he says. Sure, go ahead and assign sex at birth, he suggests,

but in the final analysis boys will be boys, girls will be girls, and they

know what they are better than any parent or doctor.

 

Some surgeries are medically necessary, and many seem to turn out just fine.

Reiner hopes to sort out some of the mysteries by following the lives of 700

children born with atypical genitals, 40 of whom had their sex reassigned at

birth. " The kids are going to tell us the answers, " he says. Cheryl Chase

thinks she knows some already. She founded the network that grew into the

Intersex Society of North America, a clan of 1,400 whose anatomy doesn't fit

the binary ideal. Born with both ovarian and testicular tissue, Cheryl

started out life as Charlie. But doctors decided later that since she was

potentially fertile and had a short penis, she'd be better off as a girl.

Her parents changed her name, threw away photographs and birthday cards and

had her clitoris removed when she was 18 months old. Her ovotestis came out

at age 8. She was in her 20s and living as a lesbian in the 1970s when she

dug up the truth about her birth and life as a boy -- making her feel like

an imposter in her own community. And for her, like many others who had

surgery on their genitals, the missing parts and scarring made sex more

likely to bring pain than pleasure.

 

The Intersex Society doesn't oppose assigning gender at birth. Instead it --

and now some medical specialists -- urges parents and doctors to refrain

from surgery and be open to a change in sex identity later.

 

But Chase, for one, isn't waiting for culture to come to terms with biology.

" I'm focused on practical changes that come quickly, not pie in the sky, "

Chase says. " I would much rather keep my clitoris and have orgasms than have

a box to check off. "

 

Helena Harmon-Smith, Patrick's mother, says she wants children like her son

to be allowed their own decisions -- and more than anything, to be

recognized as real. " My son was one of the lucky few -- because he is

technically both. He can be boy or girl, " she says. She will never forgive

Patrick's doctor for making the choice for him.

salon.com | April 5, 1999

 

 

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About the writer

Sally Lehrman is a Salon contributing writer.