The Trouble with Intersex

History Lessons

In a short talk he delivered in 2000 at the American Association for the History of Medicine, pediatric endocrinologist Jorge Daaboul reflected on the revelatory character of history in his own practice. He recounts that he had begun to have serious doubts about the standard of care that made imperative the surgical normalization of atypical genitalia in children. Though this was the standard in which he had been trained—in the tradition of Lawson Wilkins, the founder of pediatric endocrinology, and John Money, the preeminent psychologist of sexual difference—he began to pose to his colleagues the questions he had come to ask himself, namely, whether the standard was genuinely in the best interests of their young patients. The uniform responses to his questions, he told his audience in 2000, yielded two arguments in defense of the standard. First, "intersexed individuals," his colleagues told him, "could not possibly live normal lives as intersexed individuals and ... the only chance they had for happiness and psychological well being was the establishment of a secure male or female gender identity. Second, there simply was no precedent for [such individuals] living as normal people in our society" (Daaboul 2000).

Just at the time that he was engaged in these conversations, Daaboul went on to say, he read Hermaphrodites and the Medical Invention of Sex (Dreger, 1998b), Alice Dreger's account of the Victorian "discovery" of hermaphroditism. From Dreger's history he learned that until the late nineteenth century, individuals with intersex were not automatically objects of medicine as he had been trained to see them; until the start of what Dreger calls the "Age of Gonads" (1870–1915) (29), people with atypical sex anatomies in England and France lived unremarkable lives. It couldn't be, Daaboul realized, that it was necessary to correct the bodies of individuals with atypical sex in order to secure their happiness. The category of "the normal," which he had been trained to see as natural and necessary, was all at once a historical artifact. "For me," he concludes,

the study of history proved invaluable in my formulating an approach to intersex. The moment I realized that there was a historical precedent for individuals with intersex leading happy, normal productive lives I revised my approach ... and have become a strong advocate of minimal intervention. The study of the history of intersex gave me the knowledge to improve and refine my approach to this condition. Consequently, I am a better doctor to my patients. (Daaboul 2000)

Daaboul's account is compelling. It is a remarkable personal story of transformative insight ignited by the study of history and an understanding that truths one has taken for granted may be contingent—that is, neither necessary nor inevitable, but the result of human practices, actions, and ideas. In the case of atypical sex, these include truths about sex and gender, about normality and abnormality, about sickness and health. That is not to say that these categories, and what we take to be our natural responses to them, do not matter; they obviously do, for these categories are the ground from which we make sense of ourselves and each other. It is to say that what we may take to be "the way things are" could be different. Daaboul's reading of Dreger's historical account belied the training that had inculcated in him a certain vision of the way things are, of how they always would be. He now understood that many of the ways he had been taught to see the world and his patients ought to be challenged. It was this understanding, he says, that enabled him to be a "better doctor to [his] patients."

Daaboul's lesson in history invites a closer look at the meaning of the changes that prevailing beliefs, attitudes, and treatment concerning those with atypical sex have undergone. What may not be clear from Daaboul's account is the historical tension between competing views of atypical sex anatomies as a threat to the social body literally embodied by those with what was called "doubtful sex" (Dreger 1998b, 41), on the one hand, and the view that intersex is a danger to the health and well-being of those individuals with atypical sex anatomy, on the other. If this tension is not fully evident in his account, I would suggest that it is because the history turns out to be more complicated than Daaboul could have known at the time of his presentation. Daaboul's identification of his own training in the traditions of Wilkins and Money is right, I suggest in the first part of this chapter, but unraveling the threads that identify Wilkins and Money so closely lays bare important tensions in the ways that atypical sex anatomies are constituted as a "threat," first to the social order, and then to the individual who bears the alleged affliction. These competing views—the first marking the late nineteenth and early twentieth centuries, and the second the emergence from that period—intertwine in the mid-twentieth century, precisely at the point when the training Daaboul himself underwent as a physician was shaped. Existing historical accounts suggest that it was this dual constitution of the threat posed by atypical sex that prevailed at least through the end of the twentieth century. Using Daaboul's presentation as a guide, I want to clarify the historical developments that can help to make sense of how the commitments to care for "individual well-being" and what we might call "social adjustment/accommodation" may be at once in concord and conflict.

It is not often that ordinary people recognize that they are at a crossroads of historical change, and it is not entirely clear that when Daaboul made his presentation he was aware of the position he occupied in this regard. The explicit aim of his presentation was to argue for the importance of an historical sensibility, but more than a decade later we know that it is also evidence of his own place in the recent history of the medical management of atypical sex that begins with the founding of the Intersex Society of North America (ISNA) in 1993. In the second part of the chapter, I discuss another important element of this history: normalization. Michel Foucault's understanding of the power of "normalization" can help us make sense of the history of medicalization and its repressive influence; it can also guide our understanding of the significant changes that occur...