Chair:  Nancy McWilliams,Ph.D.

Presenters:  Sandra Bem, Ph.D.: A Paradoxical Lesson from Queer Theory: Degenitalizing Gender;  Nina Williams, Psy.D.: The Imposition of Gender: Genital Ambiguity in an Adult Woman

Discussant:  Cheryl Chase: Executive Director, Intersex Society of North America

 

This symposium, sponsored by Section III, concerned sexual minorities.  It proceeded from general, theoretical issues to specific, clinical ones, especially the question of contemporary medical treatment of intersexed people and its later psychological consequences.  Nancy McWilliams opened the proceedings by describing the work of the section and of Division 39 (as most of the large group attending were not Division members; it seemed an opportunity for some education about the contemporary psychoanalytic landscape).  She then framed one task of the symposium as covering theoretical, clinical and personal/political perspectives on intersexuality, the umbrella term for conditions in which one’s genitals deviate from a perceived norm.

               

The term intersexual, not to be confused with the phenomenon of transsexualism or the seeking of sex-change operations by adults, embraces what used to be called hermaphroditism as well as accidents of chromosome, hormone, and interuterine experience that create atypical genitalia such as having a clitoris that resembles a penis and vice versa.  Reliable estimates of the frequency of intersexuality have been hard to obtain.  Fausto-Sterling and her students have estimated that up to two percent of live births involve significant genital anomalies and that between .1 and .2 per cent of infants have been subjected to genital surgeries to make them appear unambiguously male or female (usually female, given that, in the chillingly flippant gallows humor of the plastic surgeon, “It’s easier to dig a hole than to build a pole”).

               

For the past forty years, mostly on Money’s now discredited arguments about the plasticity of gender identity, it has been standard American medical practice to “correct” atypical genitalia during infancy in whatever direction (male or female) is surgically most feasible.  Such operations may require lengthy medical follow-up and repetitive procedures such as the dilation of surgically created vaginas.  Typically, parents have been advised to subject their baby to surgery as early as is safe, to raise the child unambivalently as a member of the gender to which it has been assigned, and to conceal the fact that he or she was born with a genital anomaly.

               

Remarkably, there has been no systematic scientific follow-up of these treatment strategies and scant attention to the possible traumatic effect on children of both the procedures and the associated repetitive genital examinations, often conducted before numerous medical students and surgical residents.  There have been no studies of matched samples of intersexed people raised with and without early surgeries.  Ironically, the doctoral dissertation of John Money, who later championed infant genital surgeries as in the name of humanitarianism, established that intersexed people who grew up before the surgical era had lived satisfying, relatively unproblematic lives (“living testimony to the stamina of human personality in the face of sexual ambiguity” [Colapinto, 2000]).  Many people who have undergone the conventional surgical treatments of the past forty years are now adults, and some have found their way to the offices of psychoanalytic therapists.

               

In this panel, Sandra Bem first summarized contemporary literature in gender studies and related areas on the phenomenon of gender polarization and the tendency of western societies to try to fit all their members into categories of “real men” and “real women,” defined as unmistakably male, masculine, and attracted to women versus female, feminine, and attracted to men.  Reviewing the work of Judith Butler (1990), Anne Fausto-Sterling (1993), and Suzanne Kessler (1998), she described the evolution of a sensibility that seeks to dismantle conventional paradigms that exclude many people from acceptance as equal members of the human species.  She also commented on the scholarship of Mary Douglas (1966), an anthropologist who described how cultures to distinguish, based on context, between what is valued and what is considered “dirt.”  For example, although food on the table is appealing, food on one’s sweater is dirt.  Bem related these social processes to the marginalization of gays, lesbians, and other sexual minorities.  In one preliterate culture, villagers insisted that night-crowing cocks do not exist.  Investigation revealed that they systematically wring the necks of cocks who crow at night.  Comparing surgical treatment of people who are not conventionally male or female to the killing of night-crowing cocks, Bem argued that intersexed people “do not exist” because we destroy the evidence of their deviation from cultural norms.

               

Nina Williams then presented the ongoing case of a woman she has treated for four years, who entered therapy for depressive and self-esteem issues and who eventually was able to speak of her fears that she had been born with ambiguous genitalia.  This patient had numerous post-traumatic symptoms, including panic attacks when she was in the vicinity of a hospital or doctor’s office, which she related to a series of mysterious operations on her genitals that she had undergone as a young child.  When she would neglect to take hormones prescribed for a diagnosed endocrine condition, her body would masculinize.  Efforts to get her mother to talk about her medical history foundered in a sea of defensiveness.  In fact, the chronic parental mixed message of “This is too upsetting for you to be bringing up!” and “Why are you making such a big deal out of nothing?” had made the patient deeply conflicted and anxious about talking to her analyst about her body and her associated feelings, fantasies, and speculations.  With poignant imagery, Williams reported the transference-countertransference enactments that had emerged as this woman gradually found the courage to face her possible intersexuality and to convey the painful emotional context of her childhood.  For example, Williams found herself preoccupied with her patient’s anatomy at the expense of appreciating her trauma, a repetition of the way this woman’s parents (and the culture in general) have treated intersexed people.

               

Cheryl Chase, the director of the Intersex Society of North America, then responded to the issues raised by the presenters.  Beginning with an appreciation of the case, which she called a landmark contribution to understanding the psychology associated with contemporary treatment of intersexuality, she urged Williams to have it published.  In reflecting on contemporary gender scholarship, she was respectful and appreciative of the work of Bem (e.g., 1995) and those she had summarized but went on to comment that intersexed people are not particularly interested in celebrating diversity in gender and sexual orientation; they want simply to stop what they view is an inevitably traumatizing way of dealing with genital variability.  “We have a very conservative agenda,” she noted.  “We want unnecessary surgeries to stop.  We want psychological support for families and individuals coping with intersexuality, and we want people to be able to decide for themselves as adults if they want any alterations to their genitals.”  She introduced two activists for change to the current medical paradigm, Janet Green Mikkelsen and Betsy Driver, who recently persuaded the leadership of the National Organization for Women to come out against automatic genital surgery for intersexuality.  Mikkelsen and Driver both mentioned their sense of profound identification with Williams’s patient and spoke of their own struggles in therapy to come to terms to what had been done to them and concealed from them.  The intersexed participants stressed that infancy is the only time when one must examine genitals in order to determine gender; otherwise, people signal by numerous cues their identifications as male or female.  The assumption that it would be more traumatic to have unusual genitals than to undergo repetitive medical trauma and the family anguish that frequently accompanies it has never been supported with data that would constitute reliable evidence.

               

There ensued a discussion with audience members, some of whom commented on relevant psychoanalytic issues such as the dynamics involved in all versions of genital mutilation (ritual circumcision, clitoridectomy, rites of passage), in the sense of omnipotence gratified by changing a person’s gender, and in body acceptance generally.  Most members of the audience seemed eager to learn more from the intersexed people present, who were equally eager to encourage the audience members to extend clinical help to intersexed people and their families.  They emphasized their conviction that the mental health community, via its understanding of trauma and recovery, is already adequately equipped to alleviate the suffering of many people harmed by early medical trauma, secrecy, and the unprocessed family stresses that typically attend accidents of anatomy, and they urged participants to become more aware of this area of need for good psychotherapeutic services.

References

               

Bem, S. L. (1995).  Dismantling gender polarization and compulsory heterosexuality: Should we turn the volume down or up?  Journal of Sex Research, 32, 329-334.

               

Butler, J. (1990).  Gender trouble: Feminism and the subversion of identity.  New York: Routledge.

               

Colapinto, J. (2000).  As nature made him: The boy who was raised as a girl.  New York: HarperCollins.

               

Douglas, M. (1966).  Purity and danger: An analysis of the concepts of pollution and taboo.  New York: Routledge and Kegan Paul.

               

Fausto-Sterling, A. (1993).  The five sexes: Why male and female are not enough.  The Sciences, 33, 2, 19-24.

               

Kessler, S. J. (1998).  Lessons from the intersexed.  New Brunswick, NJ: Rutgers Unversity Press.