Journal of Psychoanalytic Psychology

[Betsy]

Bodies Like Ours has been given permission to reprint a case study paper by Dr. Nina Williams, a founding board member of Bodies Like Ours, has had published in the Summer 2002 issue of the Journal of Psychoanalytic Psychology.

Here's the link:

The Imposition of Gender (http://www.bodieslikeours.org/research/williams_2002_apa.html) Copyright 2002 by The American Psychological Association

Feel free to comment.

Betsy

[Natasha]

Hi Nina,

I read your paper, The Imposition of Gender: Psychoanalytic Encounters with Genital Atypicality. I am very impressed by your ability, even your willingness, to do what nearly all of the doctors and therapists I have ever been a patient of, are unable to do, and that is to question your own response to us, because you bother to consider us.

Nearly all of the treatment providers I have dealt with, seem to assume they are dealing with commodities rather than sentient beings, and are very bent on 'repacking us' or trying to discover ways of doing so more effectively. It all begins with as you put it, ".... powerfully drawn to a single question -- what is this patient’s sex? -- and to explaining their answer."

Treatment providers both medical and psychotheraputic operate from there, and subsequently all of their doings to us, or for us as they presume, are done to preserve their assumptions both about us, and sex and gender as a commodity which must pass quality control, conforming to normal or acceptable. Yet all without regard to us as people.

It seems to me as well, that another fundamental flaw of this marketing strategy, is the abject failure of most treatment providers, to realize that people whether intersexed or not, are diverse individuals who are not all the same needing the same things, who should therefore all react alike to like circumstances. The failure of treatment providers to realize that people are individuals, and their paternalistic drive to form us, remains.

I began life as an unacceptable anomaly 'which', not who, needed to be repackaged to conform to acceptable standards of normal, to be like everyone else. My feelings, my needs, what I thought or what I wanted were never considered, but ignored and dealt with as unacceptable, when I made them known.

My entire childhood was a desperate attempt to roll with the punches and accept what was dealt me, and somehow please
everyone by measuring up to something I did not grasp. So I could become worthy of the love I so desperately longed for.

Surgical modifications, made on me like a garment being made to order, was just the beginning. I was also expected to act a part quite incomprehensible to me, which required me to suppress who I already thought I was, and repress my natural way of expressing myself. I heard the director always saying, cut!, ... no no no! That is not what I am looking for! Lets try that again!

I didn't intuitively know what they wanted, or expected me to be. All I knew is, that I was not normal in ways that I did not understand, and that I did not act right. I tried to be what they wanted me to be, but I did not even know what that was. I finally settled on imitating, what little I saw of the boy next door, who wanted nothing to do with me usually. That was the best I could do. It never occurred to me to imitate my dad for some reason. He seemed far above us all, the authority, so how could I identify with him?

As an adult, finally hardened to outside pressure to conform, knowing I could not anyway and got nothing of value for attempting to, I finally decided when my own questions were answered to my satisfaction about who and what I am and what I wanted, to change from the sex I was made to be, to the one I always felt I was.

Subsequently I now realize, that what I was doing was reasserting control over my own body as best I could, and resurrecting my natural self, which was crushed and submerged. I know I am not, and never will be a biological woman. I know now there are other options also. Yet the female I am now, is the very closest I can come, to who would have been, and is the most effortless expression of who I honestly am, at least at this point in my development.

Natasha

[Betsy]

Treatment providers both medical and psychotheraputic operate from there, and subsequently all of their doings to us, or for us as they presume, are done to preserve their assumptions both about us, and sex and gender as a commodity which must pass quality control, conforming to normal or acceptable. Yet all without regard to us as people.

Dandara and I attended a paper presentation at a psychoanalytic institute last fall in NYC. The paper, presented by Jack Drescher, was full of misconceptions and was overly focused on putting IS people into a box. "they do this...; they need this...; blah blah blah"

Dandara and I sat there listening to everything that was wrong with how many within the medical and psyche community view and treat us. By the end of the Q&A period, Dandara was ready to explode and lit into them with how wrong they were.

I want to leave the exact narrative of what then occurred to Dandara (and hopefully she will respond) but it was quite the moment to behold as she stole the floor. They didn't have a clue that a couple of IS folks were sitting in the audience listening.

Betsy

[Glenn]

Very well written paper, Nina. I don't envy your struggle between your own curiosity about Kristin's past, versus helping her deal with the present.

A couple of observations on the medical perspective, mostly inspired by the phrase "uncover the roots of his normality." Medicine still seems ill equipped to deal with normalcy, and recognize the connection between the (would be) care givers and the patient.

Two examples

When I was about 14, I was in the hospital for orthopedic surgery. While in recovery, I couldn't walk, so I had to call for a nurse for things like going to the bathroom. One day, a nurse was making a big production out of turning on faucets after giving me a urinal. When I asked why she was doing this, she explained that they were concerned about my lack of output. Even at the time, I was amazed that they didn't even consider the possibility of asking me if there was a problem - they just observed the data, came up with a diagnosis, and treated the "problem." Oh BTW, I deliberately wasn't peeing often, because I had to call the nurse every time I did so. (duh!)

The other example has more to do with the normalcy quote. When I was actively supporting the midwifery community in CA, one of the recurring themes was that there was a fundamental difference between their perspective on the birthing process, versus that of physicians. Midwives recognize a wide range of normal behavior, and consider the mother and the circumstances in evaluating whether something is going "wrong" or proceeding well. Doctors judge birth by a curve (I forget who named the curve), which shows the "normal" amount of dilation of the cervix over time. If a woman has the gall not to follow that curve, then medical intervention is required to bring them in line.

The same principles are being applied to intersex conditions. "We" (doctors) will look at you, judge you, and perform medical procedures to treat the symptoms we observe. We have a bazillion years of terribly expensive training, so we don't need to bother asking your opinion. We will bring you in line so you can be normal like everyone else should be.

What is it about the way we train doctors which produces such mechanical thinking? I realize they have to distance themselves from their patients in order to be able to do their work, but that doesn't explain such shallow concepts of normalcy.

Nina - you spoke of "mistrust and shame created by parental and medical deception." How did medicine go from defining what is unhealthy, to judging what is right and wrong?

Glenn

[Natasha]

Betsy, you wrote: .... "I want to leave the exact narrative of what then occurred to Dandara (and hopefully she will respond) but it was quite the moment to behold as she stole the floor. They didn't have a clue that a couple of IS folks were sitting in the audience listening."

I wish I had been there. I would really love to read what Dandara has to say about what happened too. I hope she responds. :D

It seems to me that the cultural eminence and economic privileges conferred upon those who become doctors, convinces many of them that they are superior,and not to be questioned. I would love to see that paradigm shift!

There are a few websites of by and for doctors, who themselves decry this. Many doctors who have been in practice for a long time, teachers of medicine and the retired, wrote that the money incentive has drawn an entirely new kind of person to medicine. Those who crave the status and economic rewards. I can't remember where those sites are, sorry.

Natasha

[Nina Williams]

Thanks, Natasha and Glenn, for your feedback. I especially appreciate your sharing some of your own experiences here because I will always be learning something new, or something more deeply, about intersexed experience. Glenn, you wrote, "Nina - you spoke of "mistrust and shame created by parental and medical deception." How did medicine go from defining what is unhealthy, to judging what is right and wrong?"

Do I ever wish I knew the answer to this. The one aspect is that physicians are just like the rest of us; if they get idealized, if we expect them to know everything and fix everything (and anyone over 30 can remember a time when we treated doctors like this), they begin to believe they can, or that they at least have to keep trying. Taking a less interventionist stance (like the comparison between midwives and doctors about birth) can be seen as abdicating your authority as a physician to take decisive action quickly, which is what doctors are trained to do. I think another part is that the parents of an intersexed baby really want to believe the doctor knows how to fix "the problem" and make it go away so they can have a perfect baby, so the choice can seem to be between relieving the parents' anguish (which is visible) or prolonging it. But those are just my impressions; what do you (and others reading this) think the reason is that medicine has taken on this more judgmental position about intersexed people?

Nina

[Glenn]

Maybe the image of "perfect" doctors has finally spilled over into the legal realm. It seems like most parents will sue the universe if their baby isn't perfect. Maybe that adds to pressure for doctors to "fix everything."

And yes, there is a lot of pressure for people to become doctors for all the wrong reasons - money, social standing, family history, etc. Heck, even my mother went into nursing because of $$. *sigh*

Wishing for all the answers...
Glenn

[Dandara]

Coming unglued in front of so many psychiatrists must have kept them talking about me for awhile, but I know I made a lot more sense than the presenter.

In truth, I had gone there hoping to find the Holy Grail. It was during a time when I had so many questions, and so few answers. Surely, I thought, I would hear groundbreaking research from psychiatric geniuses that would illuminate the importance of acceptance of the individuality of each intersexed person.

What I heard instead was the dissection of one patient's life, used as a catapult to make broad assumptions of sexuality and gender for anyone that "considered" themselves to be intersexed. As Betsy said, it was about boxes and labels for the convenience of accurate diagnosis. It was if we couldn't be treated unless then could pin us down somehow.

I kept waiting for {what I thought was} the obvious:

That there are too many variables within the broad intersex framework to even begin treating us in a box.

That the common thread is shame, secrecy and deceit arising from "treatment", none of which were present at birth but were endlessly heaped upon us until we also knew the mantra of "normal", "normal", "normal".


It was an odd sensation being in a room with obviously very smart professionals, knowing that I knew more than they did. For over an hour I listened quietly but I just kept getting angrier at the realization that (once again) the professionals designated to heal us, were clueless.

I really thought I'd have a heart attack before I had a chance to take the floor, and by the time I got up in front of the smart people I was visibly shaking and too emotional for a really solid presentation of the facts seemingly overlooked in expert's presentation. But I spoke my peace about (what I believed to be) their total distraction with the sexual aspects of intersexuality, and the real and dire need to address the psychological issues and trauma inherent in surgical intervention and "treatment" under the John Money protocol. Expert and moderator were not thrilled by my impassioned plea to look beyond the labels, (and look beyond our genitals) but I know I made sense to many in the room.

Betsy and I often laugh about "the time I nearly exploded", but it was one of those defining moments in time that added to my realization of how intersexuals are mistreated, misdiagnosed, misclassified, and misunderstood.

[Nina]

I know that doctors are also individuals. There are many good doctors. I do not lump them all in as cold aloof businesspeople, bent on enforcing their personal bias regarding sex and gender.
Yet certainly many are, as witnessed by their refusal to even listen to what we ourselves tell them, of the harm done to us by them.

I think also that corporate strategy to maintain profit levels within the health care system, as imposed by HMO's etc., are in part to blame. Yet it seems to me that certainly doctors are not at all powerless, having no option but to follow orders.

You wrote: .... "Taking a less interventionist stance (like the comparison between midwives and doctors about birth) can be seen as abdicating your authority as a physician to take decisive action quickly, which is what doctors are trained to do."

Yet their first responsibility is to their patients. Is not "first do no harm", above all other considerations? Obviously not. That many doctors when faced with a choice to either "abdicate their authority' or refrain from harming their patients, chose their authority over their patients welfare, is inexcusable no matter how you look at it.

You wrote: .... "I think another part is that the parents of an intersexed baby really want to believe the doctor knows how to fix "the problem" and make it go away so they can have a perfect baby, so the choice can seem to be between relieving the parents' anguish (which is visible) or prolonging it."

The point is that the welfare of the patient comes FIRST. By their own fundamental standards as reflect in their oath, "first do no harm."

While I sympathize with the delicate position doctors are in regarding distraught parents, their overriding concern should be the welfare of their patients. The parents are NOT the patient, we are! It still remains an inexcusable flagrant violation of the first tenet of medical practice, FIRST DO NO HARM, to place the welfare of the patient, beneath any other consideration.

The emotional discomfort of parents when faced with having given birth to one of us, can be dealt with in some way that actually makes sense for a change, rather than harming us to alleviate their fears. That doctors, of any kind, use such poor rationalizations to excuse themselves, is an abdication of their responsibility as human beings. Such I believe is far more sure to undermine their "authority", in the eyes of anyone who knows the difference between those whom deserve respect, and those whom merely to fear.

Lets face it. Medicine as practiced here in America precludes adherence to the tenet first do no harm. As many without insurance and unable to pay, are denied even necessary treatment resulting in their death, or severe loss of quality of life.

That our society has not found a way to make health care humanely affordable, even within our capitalist economic system, speaks of it's collective irresponsibility. Certainly the moral failure and hypocrisy of the medical industry, is undeniable. Which yet still professes to adhere to high moral standards, while in practice denying them daily.

Natasha

[Natasha]

That ws my post.

I accidentally put Nina's name in the user name box, instead of the subject box. Please forgive my mistake.

Natasha


Originally posted by Nina
I know that doctors are also individuals. There are many good doctors. I do not lump them all in as cold aloof businesspeople, bent on enforcing their personal bias regarding sex and gender.
Yet certainly many are, as witnessed by their refusal to even listen to what we ourselves tell them, of the harm done to us by them.

I think also that corporate strategy to maintain profit levels within the health care system, as imposed by HMO's etc., are in part to blame. Yet it seems to me that certainly doctors are not at all powerless, having no option but to follow orders.

You wrote: .... "Taking a less interventionist stance (like the comparison between midwives and doctors about birth) can be seen as abdicating your authority as a physician to take decisive action quickly, which is what doctors are trained to do."

Yet their first responsibility is to their patients. Is not "first do no harm", above all other considerations? Obviously not. That many doctors when faced with a choice to either "abdicate their authority' or refrain from harming their patients, chose their authority over their patients welfare, is inexcusable no matter how you look at it.

You wrote: .... "I think another part is that the parents of an intersexed baby really want to believe the doctor knows how to fix "the problem" and make it go away so they can have a perfect baby, so the choice can seem to be between relieving the parents' anguish (which is visible) or prolonging it."

The point is that the welfare of the patient comes FIRST. By their own fundamental standards as reflect in their oath, "first do no harm."

While I sympathize with the delicate position doctors are in regarding distraught parents, their overriding concern should be the welfare of their patients. The parents are NOT the patient, we are! It still remains an inexcusable flagrant violation of the first tenet of medical practice, FIRST DO NO HARM, to place the welfare of the patient, beneath any other consideration.

The emotional discomfort of parents when faced with having given birth to one of us, can be dealt with in some way that actually makes sense for a change, rather than harming us to alleviate their fears. That doctors, of any kind, use such poor rationalizations to excuse themselves, is an abdication of their responsibility as human beings. Such I believe is far more sure to undermine their "authority", in the eyes of anyone who knows the difference between those whom deserve respect, and those whom merely to fear.

Lets face it. Medicine as practiced here in America precludes adherence to the tenet first do no harm. As many without insurance and unable to pay, are denied even necessary treatment resulting in their death, or severe loss of quality of life.

That our society has not found a way to make health care humanely affordable, even within our capitalist economic system, speaks of it's collective irresponsibility. Certainly the moral failure and hypocrisy of the medical industry, is undeniable. Which yet still professes to adhere to high moral standards, while in practice denying them daily.

Natasha

[Nina Williams]

When I responded to Glenn's question about how doctors got caught up in deciding what was right and wrong, I was not defending them. I think the medical treatment of intersexed people in the last fifty years is appalling. That's why I'm dedicated to changing this practice. But I do think that placing all the blame on doctors, when medical economics, sexual politics, homophobia, and hatred of women all also play key roles, is to risk leaving intact the cultural influences that gave doctors this sort of authority. As one example, The New York Times estmated last year that 75% of clinical medicine is not research-based, although both physicians and patients seem to believe that medicine is nearly always science. This seems like wishful thinking on everyone's part that we knew how to control things we can't or shouldn't. I think the world has been impoverished by the destruction of intersexed bodies and voices. And Dandara's sttory demonstrates the consequences of this. The practice of psychotherapy has become inundated with the same ideas of empirically based treatments and diagnosing all variations as disorders, so instead of doctors seeing how people with different bodies and histories can make their way in the world, we're only getting the message that we should get everyone into a category and make them 'normal'.

Nina

[Natasha]

Hi Nina,

You wrote: .... :When I responded to Glenn's question about how doctors got caught up in deciding what was right and wrong, I was not defending them."

I understand that. I did not accuse of such, but I did 'react' to the restatement of what are often used as excuses by apologists for gendercide. I should have 'responded' more coolly, and made it clear, that I know you are not an apologist. That is my bad. Please excuse me.

It is just so difficult Nina, and ever increasingly so, for me to be dispassionate about any of this. I hope you understand, and I imagine that you do.

You wrote: .... "But I do think that placing all the blame on doctors, when medical economics, sexual politics, homophobia, and hatred of women all also play key roles, is to risk leaving intact the cultural influences that gave doctors this sort of authority."

I agree. Doctors are also a product of our culture. Harmful cultural assumptions about women, sexual minorities of all kinds, convoluted complex and partisan sexual politics, as well as the structure of our economic system, are all part of the problem.

Certainly antihuman cultural influences must be addressed, rather than simply leveling blame on those who directly harm us in any circumstance. Yet I believe that each individual is still responsible for what they do regardless.

Natasha

[Unregistered]

Hi Dandara,

You wrote: .... "Betsy and I often laugh about "the time I nearly exploded", but it was one of those defining moments in time that added to my realization of how intersexuals are mistreated, misdiagnosed, misclassified, and misunderstood."

Thank you from the bottom of my heart for honoring my request. I really liked your post!

I imagine I may have reacted in a very similar fashion. I know I would have been shaking with anger, but I am not so sure that at that time in my life, I would have had the guts you displayed. Way to go Dandara!

It would not surprise me in the least, if the lasting impression you left upon them is far more than a defining moment in time.

Thank you Dandara.

Natasha

[Betsy]

Patterson K. What doctors don't know (almost everything) NYTimes. May 5, 2002

"The most radical change evidence-based medicine proposes will occur in everyday visits in doctor's offices--those simple, scary moments when the most important medical decisions are made. The instant the practitioner stops saying, "I think you should take this therapy," and starts saying, "The evidence is that this therapy will work will this percent of the time, with these complications, this frequently; what do you want me to do?" Then the power hierarchy of doctor over patient is collapsed, and autonomy is assigned to the patient. This is how the relationship between doctor and patient could be changed by evidence-based medicine. Just as the idea of authority within medicine is rejected, so too, the idea of the profession of medicine itself having authority over the patient is rejected."

Betsy