Intersexuality: Physical and Psychological Implications of Ambiguous Sex
Growing up I remember “Fred and Wilma”, “Mickey and Minnie”, “Ricky and Lucy”, and of course “Ward and June”, “Carol and Mike Brady”, and “the Professor and Mary Ann.” There were never areas of gray. Mom and Dad were old-fashioned role models. “Gentleman opened doors, held a steady job, was the head of the house” according to my parents. Women were to keep themselves attractive, be a good housewife, and a caring mother. The gender roles were never a question. My friends were all living in the same world. Little did I know that I was living in a box? That my life was so simple and yet others struggled with their very existence every morning the rolled out of bed. “Fred and Wilma” was just another stereotype they didn’t fit into. I’m speaking of those born of Ambiguous Sex.
Intersexuality is not a new research find. Scientists and Doctors have studied this puzzling anatomical abnormality for many years. The definition of intersexuality is “some mixture of male and female anatomical characteristics, often reflected in the presence of ambiguous genitalia.” (Kelly, 2006) However, this definition only reflects the simplicity of the physical challenge. There is far more to understand about the psychological implications that also connect to the physical dilemma of this condition.
Kelly asks the question “If your child were born intersexed, what course of action would you consider?” (Kelly, 2006) I know for myself this would be a horrific decision to make. Are there alternatives? What does this mean to my child? Do I have a right to make this decision for them? Does anyone? Who is my child on the inside? I think there are so many questions that need to be examined prior to determining an ambiguous sex child.
To better understand intersexuality, we need to first examine the scientific data we have knowledge of. Our sex is determined at conception. Every person is born with chromosomes contributed from the mother and father. The mother contributes an “X” chromosome and the father contributes either another “X” chromosome producing a female, or a “Y” chromosome for a male. These chromosomes will begin to formulate genitalia in the fetus according to the pair that was received. Ambiguous sex happens when there is a disruption of the process in the fetus while genitalia are being formed. (Goldenring, 2005). The exact causes for this disruption are not known at this time.
Variations for females can include: “enlarged clitoris, urethral opening, fused labia resembling a scrotum, and a child may be raised as male with undescended testicles.” Male variations can include: “abnormally small penis that resembles an enlarged clitoris, misplaced urethral opening anywhere along the penis and as low as the peritoneum further enhancing the appearance of a female, a small scrotum with a degree of separation resembling a labia, and undescended testicles.” (Goldenring, 2005)
According to Dr. Goldenring, M.D., MPH, Department of Pediatrics, Children’s Hospital, San Diego, CA, “a decision should be made within a few days as to raising the child as male or female” and tests can be run to determine the extent of which sex the child is more likely to be. Surgeries will then be performed to transform the child’s sex into a more gender-typed physical appearance. Dr. Goldenring does acknowledge there will be psychological and social implications accompanying these procedures and counseling is recommended.
Taking perspective in a psychological view is an article entitled “Ambiguous Sex”or Ambivalent Medicine? Ethical Issues in the Treatment of Intersexuality” by A. D. Dreger. Ms. Dreger charges that not all sexual alteration surgeries being performed are with informed consent. The research examines the criteria physicians use to determine sex for an ambiguous infant. Ms. Dreger’s pragmatic depiction of reconstruction clearly shows doctors’ bias on creating female over male. The choice is determined solely on the ease of creating a vaginal opening over an “acceptable” penis. Her point was clearly stressed that there is complete disregard for normal function of the created genitalia and the traumatic; life long effects a woman may have from such a choice. This may be an easy process for a talented surgeon, but it goes way beyond physical reconstructive success.
In further depth, the article goes on to examine the damaging psychosocial outcome of AIS and intersexuality patients who have been deceived while growing up and even stretching into adulthood. Physicians “selectively withholding” crucial biological information and parents sustaining the masquerade from infancy to adulthood solidify gender confusion and raise a major question of breached ethics.
The findings reflect adults who are attempting to conform to a role that a doctor, parents and society has assigned them, not necessarily what they are biologically wired to be. Some can adjust but never seem to be completely assimilated. Others experience extreme psychological disaster. Ms. Dredger’s core implication is clearly the profound psychological affects of assigning sex to an ambiguous sex infant.
In reading this article, I reflect on the birth of my own two children. I remember how anxious I was to see if they were “normal.” Never in my mind did I consider the possibility of an ambiguous sex crisis. Most parents do not think of this. It is thought to be a rare occurrence but the research presents a 1 in 1500 live birth statistic (Dreger, 1998). This number is drastically increased by including those children born with what is considered cosmetically “unacceptable” genitalia (1998).
Our culture clearly defines the roles of male and female. Family generations reinforce these stereotypes. Parents, in my opinion, hold the most immediate and possibly greatest influence on a child. In the cases examined in this article, it is unconscionable that biological histories were withheld from these patients, even as adults.
Denying this information during early development can interrupt normal growth patterns. The mind will be in constant conflict as biological developments continue. The psyche will continually try to override sexual urges and impulse signs thus creating gender confusion. The patient may experience struggle with an underdeveloped ego. They can be extremely introverted to hide the inner conflict. This will create vulnerability and also impede them from experiencing true self-realization. They will only know the person they are “expected” to be.
Parents presenting an expected “gender role” are damaging. There are many psychologically traumatic possibilities that could occur from a negative parental role-model. Freud’s Oedipal Complex theory and phallic stage theory immediately come to mind in these cases. Some patients may be unable to reach the Genital stage due to constant internal mental conflict reinforced by dominating parental guidance. Research in this article shows some patients struggle with homosexuality, some exist in constant state of defense exhibiting reaction formation, repression, isolation, and denial. Integrating psychoanalysis at an early stage may be able to offer a hope of balance and harmony for not just the patient but for parents and family members as well.
It is suggested in the article that a team of specialists go to work within the first 48 hours of birth to present the opportunity of “natural” sex development (1998). This also correlates with the contemporary theory by John Money that children’s sex needs to be determined very early in life and psychosocial rearing (nurturing) will develop the gender as opposed to biological makeup (1998).
With support groups like the ISNA Intersex Society of North America, education, understanding and acceptance is more prevalent today. ISNA’s mission is to eliminate unnecessary surgeries of gender choice by unqualified doctors, end shame and secrecy of this condition, strengthen the awareness of these DSDs (disorders of sexual development) and protect the rights of the children and families involved (ISNA, 2006).
Since 1993, the ISNA has been a resource and advocate for parents and intersex children. Recently, ISNA posted an article addressing corrective surgeries, similar to the ones discussed by Ms. Dreger, only on adult females with DSD. The article is “Adult Genital Surgery for Intersex: A Solution to What Problem?” by Mary E. Boyle, Susan Smith, and Lih-mei Liao. Posted on ISNA website, this article addresses problems that parallel the childhood surgery for genital correction. The complications and trauma involved far outweigh the corrective measures attempted, according to Ms. Boyle, Ms. Smith and Ms. Lih-mei.
According to the ISNA, one percent of live births are born with some type of DSD. The problem with this is the determination of what exactly determines intersex? Intersex, hermaphrodite, transgender, and androgynous or ambiguous sex are all terms used but most mean slightly different conditions or identifications.
Intersexuality is being studied more today than ever. Lobbyists are active to bring attention to these conditions and some of the unacceptable practices being performed by doctors, therapists and parents. The children involved need more protection of their rights according to the ISNA.
Psychologist John Money, previously mentioned in Dreger’s article, is one of the reasons for the Intersex Rights Movement. He was the therapist for David Reimer, a young victim of a botched circumcision. David was a healthy male twin and at the age of 8 months, a doctor performing a circumcision, accidentally burned off David’s penis. At the recommendation of respected Johns Hopkins Medical Center, the doctor and Money, David was then raised as a girl. John Money professionally claimed that David was well adjusted but David confessed a different opinion in early adulthood. This determined a need for a rights movement and it has been supported and gaining steam since. The ISNA continues to support the Intersex Rights Movement and continues to educate tens of thousands of people about DSDs and the victims involved in past tragic incidents like David Reimer (ISNA, 2006).
In summation, the frightening reality that intersexuality exists and still remains unsettled. The articles and websites researched for this paper positively heightens the awareness of ethics. It also brings to light social and cultural pressures and how we far one can be influenced by them. It is clear that both physicians and parents will have the initial decision of gender definition at birth. Dr. Goldenring outlines the scientific mystery behind the condition while Ms. Dreger exemplifies the need for more psychoanalysis of intersex subjects from birth to adulthood. She also reassures the need for skilled therapists to become involved early in life with not only the patient but surrounding family to increase the chance of raising a balanced individual. The ISNA continues to rally for support of Intersex Rights and offers education on the various DSDs that occur. They continue to offer support for families of these children and educate the general population toward acceptance and toleration of these individuals regardless of the choices made toward their gender identity. This triangle of science, psychology and humanity continues to work closer toward a better overall understanding to do what is best for all involved for a healthy life. We do not yet have the answers but every day is a day closer to them.
Dreger, A. D. (1998). “Ambiguous sex”-or ambivalent medicine? The Hastings Center Report May/Jun 1998, Volume 28, Issue 3, 11/06/06, Intersex Society of North America, http://isna.org/articles/ambivalent_medicine
Goldenring, J. MD MPH (2005). Ambiguous genitalia. Healthline, 11/5/06, http://www.healthline.com/adamcontent/ambiguous-genitalia
Intersex Society of North America, 2006. 11/08/06, http://www.isna.org/
Kelly, G. (2006) Sexuality today the human perspective. New York.