PERFORMING SEXES AND GENDERS IN MEDICAL PRACTICES

Stefan Hirschauer

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To talk of differences in medicine is to evoke the vast array of heterogeneous discourses and practices among different medical disciplines, settings, and groups, and the various diseases and bodies incorporated in these discourses and practices. This chapter contributes to this discussion by showing how three medical disciplines involved in a sex change determine the sex of an individual and how they define the meaning of "sex" by various differentiating practices: practices that set apart, divide, distinguish, categorize, classify, segregate, dissect, discriminate, and separate.

The specific case of sex change also raises the question of how a difference already made in everyday life (the sex difference) is drawn into, reproduced, and changed in medicine. This question of "differences in medicine" concerns the way in which medical disciplines reconstruct, protect, and mould the life-world distinction between men and women. And by looking at how medical practice is embedded in a wider cultural context, we are also able to see how the disunity of medicine can be induced and reduced by this context.

Some of the practices that construct "sexes" in everyday life are well known through ethnomethodological and interactionist research. Participants in public and private interactions maintain ongoing processes of gender presentation and gender attribution in order to display and categorize each other as members of a specific sex category (Garfinkel 1967; Goffman 1976; Kessler and McKenna 1978; West and Zimmerman 1987). In current feminist contributions on the performance of gender (Butler 1990), these phenomena have given rise to theories of the contingency and esthetic multitude of gender. Unfortunately, poststructural discourse analysis has not taken into account empirical explorations of the performative dimension of sex membership. In fact, it has highlighted the contingency of gender by implicitly contrasting it with a biomedical notion of sex as a monolithic, ontological entity. Since outside of identity politics there is no need to oppose ontologies, I will try, instead, in this essay to reconstruct the ontologies inherent in different medical practices.

From the biographical perspective, the process of sexing an individual starts in a medical setting: in the deciphering of the gray shadows of ultrasound pictures or—more important for the legal fixing of gender—at birth. Knowing that the strange creature emerging there must be either a "boy" or a "girl," a doctor or a midwife takes certain anatomical features as a good reason to apply one or other gender category to the baby.

To understand transsexuality as a social phenomenon, it is useful to think of it as a delayed revocation of that first attribution: "No, I'm not a girl. I'm a boy." Such a revocation leads to uncertain social situations with opposing categorizations, that is, to a micropolitical conflict between, on the one hand, a person making a verbal claim to being one gender and, on the other hand, people in his/her environment who believe him/her to be the other gender because of his/her public appearance or their past knowledge of this person. Two parties emerge here: the first is the majority of people, embarrassed by this severe interruption of the routine workings of their classificatory practices; the second is that tiny minority who develop a modest rhetoric of self-determination as a consequence of their political weakness. They don't aggressively claim to be the other gender or simply live as such, but they subjectively feel it "inside."

In the history of the medicalization of this social conflict, such clashes have been reconstructed as divides between "body" and "soul," "sex" and "gender" (Stoller 1968)—divisions that reflect territories of different medical disciplines. These divides have given rise to the well-known formula of a person with a "female (or male) soul being captured in a wrong body." The formula has a life-world predecessor. In nineteenth-century Germany it was framed in moral language that implied that gender deviants (called Urninge) had the wrong body, given their sexual preferences: "What we do is not false, what is false is our body." At the end of the nineteenth century this sense of wrongness acquired theoretical meaning, with the development of a biological etiology and symptomatology for homosexuals. Finally, since the 1920s, the wrongness has acquired pragmatic meaning with the development of genital surgery. A body now can be experienced as "wrong" because it can be corrected.

The delegation of the problem to medicine has also shifted its controversial character into medicine. The disunity of people in families and at places of work over the gender of an individual became a profound disunity within medicine, which was expressed in heated ethical debates about the legitimacy of genital surgery. The micropolitical conflict about whose gender definition must adapt itself was transformed into a question of medical treatment: whether one should adapt the soul to the body psychiatrically or the body to the soul surgically. And social conflicts about the validity of gender migrants' claims were transformed into theoretical controversies about nosological classification: labeling transsexuality a psychotic condition, a neuroendocrinopathy, a borderline syndrome, or a creative defense mechanism—each implied a political position with regard to the social conflict.

The debates were largely settled in the 1960s with the formation of interdisciplinary treatment programs for transsexuals, where careful selection of candidates was designed to guarantee a successful sex change under medical management (Green and Money 1969). Professionals participating in such programs included psychiatrists, urologists, gynecologists, plastic surgeons, endocrinologists, medical practitioners, voice therapists, cosmeticians, social workers, and legal experts.

In what follows, I will describe some aspects of this treatment program, which I studied in a two-year ethnographic project in Germany. I will concentrate on the three most important medical disciplines, ignoring other professions and some of the local differences. I make use of an ideal-typical description of practices that enables the contrasts and comparisons...