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Why can't we go on as three?

Common sense is the watchword of a good clinician. And common sense tells us that the world of human beings is divided into male and female, boys and girls, men and women. Or does it? Wittgenstein once wrote, "If you believe that our concepts are the right ones, the ones suited to intelligent human beings, that anyone with different ones would not realize something that we realize, then imagine certain general facts of nature different from the way they are, and conceptual structures different from our own will appear natural to you."[1] To see something of what Wittgenstein is getting at here, consider the following story.

In the 1970s Juliane Imperato-McGinley and colleagues published studies identifying a rare deficiency of testosterone metabolism, 5-alpha-reductase deficiency syndrome.[2] Children with this condition are genetically XY, but are born sexually ambiguous. In the rural Dominican Republic where the studies were conducted, these children are often raised as girls. Until puberty, that is. Because when the children reach puberty they undergo striking changes. Their voices deepen; their muscles develop; their testes descend; and what was thought to be a clitoris enlarges to become more like a penis. The child who was thought to be a girl, or sexually ambiguous, gradually becomes a boy. Dominican Republic villagers call these children guevedoce, or "penis at twelve."

How you see this case (as with any case) will depend on where you are standing. For the U.S. researchers who published the study, it looks like a case of mistaken sexual identity: genetic boys who were raised as girls, and whose true sexual identity emerges only at puberty. Imperato-McGinley and colleagues point to the influence of normal levels of testosterone on the brains of these children in utero, neonatally, and at puberty. Once these children began to appear male rather than female during puberty, they were able to change from being female to being male with relative ease. They gradually began to feel less like girls and more like boys; eventually, they came to see themselves as men. Of the eighteen children followed in the study who were raised as girls, seventeen changed to a male gender identity during puberty. Sixteen changed to a male gender role, working as farmers and doing other traditionally male work, and fifteen of them went on to marry women. For those of us whose world is divided into men and women, like these U.S. researchers, the relative ease of this female-to-male transformation looks like evidence that (contrary to the theories of Money and others) in matters of sexual identity, biology outweighs socialization. In the end, testosterone prevailed.

But this is not the only way to see this case. Gilbert Herdt has argued that what we see here is not so much a case of mistaken sex as a culture with a "third sex"; that the transition from female to male was unproblematic not because of male biology and a laissez faire attitude toward sexual identity, as the U.S researchers assumed, but because the local Dominican Republic culture into which these children were born recognizes a third-sex category: guevedoce.[3] Not all cultures code for two sexes the way Western cultures do, and in the areas of the Dominican Republic where 5-alpha-reductase deficiency is common, "the villagers have more than a simple word for hermaphrodite; they have a triadic sexual code" (p. 428). Thus the sexually ambiguous child is born not into a world divided up into male and female, but into a world divided into male, female, and guevedoce. Different concepts, different facts of nature.

In fact, we don't even need to postulate different facts of nature, only (as Wittgenstein would say) different forms of life. History and anthropology have shown us many societies whose conceptions of sex and gender are vastly different from our own. One of the best known examples of a third sex/third gender are the berdaches of traditional North American societies.[4] Berdaches defy easy categorization in our terms--they are sometimes described as men who adopt the dress and gender roles of women--but it seems clear that at least some of them are intersexed, such as the nadleeh in Willard Hill's 1935 study, "The Status of The Hermaphrodite and Transvestite in Navaho Culture."[5] What is striking about the Navajo nadleeh in Hill's study is not simply the fact that the culture codes for and accepts a third-sex/third-gender category, but the status and prestige the nadleeh are accorded. "You must respect a nadle," one Navajo elder tells Hill. "They are, somehow, sacred and holy." A family into which a nadleeh is born is considered very fortunate, because a nadleeh ensures wealth and success. They are made heads of the family and are given control of family property. "They know everything. They can do both the work of a man and a woman," another Navajo says. Still another: "If there were no nadle, the country would change. They are responsible for all the wealth in the country. If there were no more left, the horses, sheep and Navaho would all go. They are leaders just like President Roosevelt" (p. 274).

The issue dividing us and the Navajo, as Clifford Geertz suggests in one of his more dazzling turns, is one of commonsense judgments, our untutored, no-nonsense, matter-of-fact attitudes toward the world.[6] It isn't just that what the Navajo call nadleeh we call hermaphrodites or transvestites, or that what certain Dominican Republic villagers call guevedoce we call (some of us, anyway) 5-alpha-reductase deficiency syndrome. The difference lies in our basic apprehensions of the obvious, the way life is, once it is stripped of artifice and theory and intellectual pretensions: the things anyone knows (or at least anyone with a lick of sense). Knowing that you shouldn't play with fire, that sugar causes tooth decay, that (as all Southerners know) you can't make good barbecue and comply with the health code: this is all common sense. And so, argues Geertz, is the idea that human beings come in two varieties. Or three, as the case may be, since according to Geertz, common sense is itself a local cultural system.

For Geertz, intersexuality is so problematic for Americans because it defies our common sense. To see Geertz's point imagine yourself the mother or father of an intersexed newborn. Imagine further that you must answer the questions of relatives and friends about the sex of your child. It is one thing to say that it is not immediately dear whether the child is a boy or a girl, as clinicians often recommend, because of a medical condition. Such an admission would, for Americans, be embarrassing enough. But it would be far preferable to saying that your child is neither male nor female but a hermaphrodite. For most Americans, I suspect, this would be unthinkable. The condition of having both male and female sexual organs is something that cannot be openly admitted. Americans, as Geertz puts it, "apparently regard femaleness and maleness as exhausting the natural categories in which persons can conceivably come: What falls between is a darkness, an offense against reason" (p. 85).

This offense against reason is precisely what concerns Alice Dreger, whose persuasive and insightful paper represents a growing body of scholarship that challenges our way of dividing up the world of sexual identity: scholarship from history, literature, anthropology, philosophy, cultural studies, gender studies--just about every discipline, it seems, except bioethics. The reason for this absence of attention, as Dreger makes very clear, is not because the issue is invisible in hospitals or inconsequential for patients. How should we Westerners treat children whose anatomy and physiology challenge our commonsense notions of sexual identity?

Dreger argues convincingly that the price of secrecy and deception about normalizing surgery is not worth paying here, no matter how well-meaning it is. The very secrecy that is intended to alleviate feelings of freakishness, she suggests, may in the end only exaggerate them. I think she is right. But it is important to realize that there is also an internal therapeutic logic to this deception. According to this logic, intersexuals are deceived not simply because they can't handle the truth, but because deception is thought to be a necessary part of the treatment. To be (for example) a female the child must really believe she is a female. If she doesn't unquestioningly believe she is a female she may not grow to identify herself as female; and if she does not identify herself as female then she is not a female. (Or at least not simply a female.) The same kind of logic goes for the practice of deceiving parents, and for undertaking the treatment as early as possible, before the child is able to give consent. Sexual identity is largely determined by socialization and anatomical appearance, this line of reasoning goes, so if parents do not unquestioningly believe that the child is female, their doubts will become apparent to the child. The child will then have doubts herself, and consequently her own identity will come into question. This rationale is apparent in instructions to endocrinologists such as these: "There should never be any doubt in the mind of parent or patient that a child is being reared in his or her own `true sex'..."[7]

True sex: this is a revealing phrase. Parents must believe that treatment is not altering their child's sexual identity, but that it is restoring the child's true sex, which has been masked by pathology. Parents must not have any question that the true sex of the child, underneath all the surface aberrations, is straight-forwardly male or female. Yet it is when we pass into this shadow territory between illness and identity that matters become hazy. We would like to think that the border between who a person is and what illness she has is easy to spot; that curing an illness is very different from altering identity. But things aren't nearly so simple. Deaf culture advocates have made it plain that deafness is not simply the absence of hearing but an essential part of their selfhood, part of a living culture with its own language, history, stories, and institutions. Nor was it was so long ago that homosexuality was considered a mental illness, rather than a constituent of the way some people are. Genetic variation is perhaps the haziest area of all. We used to have all manner of descriptors for human variation--many of them vaguely derogatory: mongoloids, dwarves, imbeciles, hermaphrodites--that have now been replaced by the language of genetic illness and disorder. Often, it seems, illness is identity. You are what you are afflicted by.

Which can make all this something more than a matter of cosmetic surgery. The issue is not just making genitalia that look and function better, or at least not always. It can also be a matter of assigning an identity. Yet some guidelines treat the issue as essentially cosmetic, and often seem to be based on criteria that are, in comparison to the gravity of the decision and the invasiveness of the surgery, rather difficult to take seriously. One standard endocrinology textbook says that in deciding whether to give a male pseudohermaphrodite a male sex assignment, "The basic questions to ask are 1) will the child be able to urinate standing? and 2) will sexual intercourse as a man be possible?"[8] Many men, I will venture to say, would consider the ability to use a urinal comfortably one of their less crucial biological capacities, and certainly less important than many of the matters about which there seem to be so little long-term data. One wants to know: how will the sexual identity of an intersexed child develop? Under what circumstances, and after what procedures, do such children come to think of themselves as men, or as women, or most crucially, as something else? What are their sex lives like? Are they happy? These are the kinds of questions that I can imagine parents wanting answers to before they consent to treatment.

Dreger compares the practice of clitoral reduction for some intersexed children to that of female circumcision (or female genital mutilation) in parts of Africa. While she does not defend the African practice, she points out that the notions motivating clitoral reduction of intersexed infants--that a clitoris has a proper size, and that a clitoris which is too big can be damaging to the psychosocial welt-being of a child--are, like the African procedures, a product of local culture and custom. Only they are our customs, the dictates of common sense, and so we take them very seriously.

Yet at the same time it is hard to blame parents for seeking or consenting to surgery for their intersexed children, especially if the child's genitalia and secondary sexual characteristics are a more obvious mix of male and female anatomy. I suspect parents are often terrified at the thought of their child being an outcast, of being seen as a freak of nature, of being desperately unhappy, of being completely bewildered about their place in the world, of never being able to attract a sexual partner, of being forced to live a life of secrecy and shame, of being tortured and bullied and ridiculed by other children while they are growing up. And who is to say that parents' fears are not justified? It would be a mistake to overlook the consequences of damaging and stigmatizing cultural pressures an intersexed child may face. We might think the Navajo in the 1930s were more enlightened than we are today, but we can't simply decide to see the world that way. We have the culture that we have, and we live in the present, not the past. Cultures change, of course, and it is more likely that ours will change if fewer surgeries are done and intersexuality is acknowledged openly. But few parents will willingly risk what they believe to be the well-being of their child in order to protest a cultural norm.

Cultural critics often describe physicians who perform intersex interventions as shoring up our categories of sex and gender, or trying to protect the established cultural system from chaos, or framing intersexuality as something to be eradicated.[9] These descriptions are accurate in their own way, I suppose, but they misleadingly imply a kind of agency on the part of doctors, a conscious effort to fend off threats to a cultural order. One might say with equal accuracy that doctors are trapped by this order themselves, imprisoned in a cell with only one window on the world. The fact is, we treat these children the way we do because this is how we see the world. And it isn't just the way doctors see the world; it is the way parents see the world, and most importantly, it is the way that the children themselves are taught to see the world. It is the fact that they do not fit into this way of seeing the world that causes the problems.


This work is part of the "Enhancement Technologies and Human Identity" project funded by the Social Sciences and Humanities Research Council of Canada.


[1.] Ludwig Wittgenstein, Remarks on the Philosophy of Psychology, vol. I, ed. G.E.M. Anscombe and G. H. Von Wright (Oxford: Blackwell, 1980), p. 48.

[2.] Juliame Imperato-McGinley et al., "Steriod 5-alpha Reductase Deficiency in Man: An Inherited Form of Male Pseudohermaphroditism," Science 186 (1974): 1213-15; Juliane Imperato-McGinley et al., "Androgens and the Evolution of Male-Gender Identity among Male Pseudohermaphrodites with 5-alpha Reductase Deficiency," NEJM 300 (1979): 1235-36.

[3.] Gilbert Herdt, "Mistaken Sex: Culture, Biology and the Third Sex in New Guinea," in Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History ed. Gilbert Herdt (New York: Zone Books, 1996), pp. 419-45.

[4.] See, for example, Walter Williams, The Spirit and the Flesh: Sexual Diversity in American Indian Culture (Boston: Beacon Press, 1986), and Will Roscoe, The Zuni Man-Woman (Albuquerque: University of New Mexico Press, 1991). Indeed, some scholars identify even more complex systems of sex/gender categories in native American cultures, for example Wesley Thomas, "Gendering Navajo Bodies: Cultural Constructions of Gender and Sexuality." (Doctoral Thesis, University of Washington, communication from the author.)

[5.] Willard W. Hill, "The Status of The Hermaphrodite and Transvestite in Navaho Culture," American Anthropologist 37 (1935): 273-79. Hill uses older, no longer preferred spellings of Navajo terms.

[6.] Clifford Geertz, "Common Sense as a Cultural System," in Local Knowledge: Further Essays in Interpretative Anthropology (New York: Basic Books, 1983), pp. 73-93.

[7.] Melvin Grumbach and Felix Conte, "Disorders of Sex Differentiation," in Williams Textbook of Endocrinology, 8th ed., ed. Jean D. Wilson and Daniel W. Foster (Philadelphia: W. B. Saunders, 1992), p. 937.

[8.] Maria I. New, "Congenital Adrenal Hyperplasia," in Endocrinology ed. Leslie J. DeGroot et al. (Philadelphia: W. B. Saunders, 1995), p. 1829.

[9.] Julia Epstein, Altered Conditions: Disease, Medicine and Storytelling (New York: Routledge, 1995), p. 81.
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Title Annotation:intersexuality as a third-sex category
Author:Elliott, Carl
Publication:The Hastings Center Report
Date:May 1, 1998
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