Medical Articles on the Littleton Case
and Related Articles on
Gender Determination and Human Rights

Hermaphrodites and the Medical Invention of Sex
by Alice Domurat Dreger, 268 pp, with illus, $35, ISBN 0-674-08927-8, Cambridge, Mass, Harvard University Press, 1998.
Reviewed by
Author Information  Domeena C. Renshaw, MD

The International Olympic Committee (IOC) in our dimorphic (two-sex only) world mandates for all women competitors a buccal smear for XY chromosomes (rather than for each to appear nude before a panel of doctors). In 1992, DNA tests were used instead and criticized as being too sensitive. Several renowned geneticists protest all such sex testing as absurd and discriminatory because there is so wide a spectrum of existing intersex conditions. It has been said (unverified because the IOC claimed confidentiality of records) that 1:500 women were disqualified in this way from the 1996 Olympic Games. The impact on the lives of the athletes involved remains an untold story. The IOC goal is to eliminate unfairness, eg, female impersonators or transsexuals. The International Amateur Athletic Federation (IAAF) favors a physical examination report by the woman athlete's own physician, but spot-check examinations may be done by IAAF physicians.

Gender exceptions have inspired this well-written history of encounters between medical practitioners of the late 19th century and women patients who sought help because they could not complete the marital act. The examining physician would become perplexed to find unusual genitals and one or two testes in a woman patient who, he then told her, was a "masked" male; distress would follow. Her husband was male, and she was now diagnosed as male, which made theirs an illegal homosexual marriage. These social, legal, and moral sequelae led to much general medical concern. Great and lively academic debate resulted in England and in Europe whenever a case was reported. The report's form is an important mirror into our medical past.

The era preceded hormonal and chromosomal blood studies. Variant genitals threatened, then as now, the stability of a male-female society. Meticulous, fascinating case histories, photographs, and histological slides of testes and ovaries were presented by scientists. Bearded women and menstruating men were studied and carefully documented. "Hermaphroditism" (from the mythical union of the Greek gods Hermes and Aphrodite) was until 1915 the blanket term used for any person with "double sex" or doubtful genitals.

Medical opinion slowly began to question the emphasis on ovaries and testes as the only sexual indicators. The size of the baby's penis was preferred for assigning sex as male. It was well known from study of miscarried embryos that the fetus had potential for the anatomy of either sex. Incomplete or interrupted development, or nondevelopment, resulted in a wide array of genital problems at birth. In several early cultures, the hermaphrodite or intersex infant, if recognized, was considered a "bad omen" and left to die. The undiagnosed, untreated adult hermaphrodite might have been reared as either boy or girl, after random sex assignment by midwife, grandmother, or parents. Lack of menstrual periods a century ago did not seem reason to seek rapid medical attention. Rather, increase in the size of testes at puberty causing pain or pressure (often presumed to be a hernia) and coital problems were the two most frequent presenting medical complaints.

By the late teens, gender behavior and identity as feminine or masculine are firmly fixed. Life could and still can be totally toppled by a medical confrontation. As Dreger describes, Sophie at age 42 years was told by the French physician, Professor Michaux, when he found testes and a shallow vagina, "My good woman, you are a man." Sophie thought the doctor was crazy and disappeared after that single visit, but the case was published. Other diagnosed patients switched sex roles under physician direction, hence "The Medical Invention of Sex." It was risky to go to a doctor if you were a secret or undetected hermaphrodite because a sudden gender role reversal might result from a medical examination.

Scientific literature of the time called the patient a "monstrosity of nature," a "specimen," a "masked male," and a "wolf in the sheepfold" (still sleeping with female relatives). Homosexuality at the time was called "inverted" sexuality and was sporadically documented as being caused by hermaphroditism, although this assumption was vigorously disclaimed as totally erroneous by Havelock Ellis and Krafft-Ebing. Certainly hermaphrodites were the exotica of erotica at the turn of the century. Some were paid to be presented at medical meetings or in traveling shows with other so-called medical freaks, such as conjoined twins and dwarfs, a way to earn a living.

Some physicians spent years in the special study of hermaphrodites. A Polish gynecologist, F. Neugenbauer, published in German in 1908 a study of 2000 cases, many from antiquity. In 20 years, he had been consulted on 40 cases. His goal was to prevent the condition by early diagnosis and management to avoid the personal disruptions and even tragedies he noted when adult intersex patients newly discovered their "doubtful/double" sex. Several physicians objected to the blanket term hermaphrodite as too confusing, saying it was wrongly used and overused, and medical debates became bitter.

Testes were sometimes secretly removed to compassionately "allow" a female hermaphrodite to continue as a woman in 1920. What was not known until 5 decades later was that the testes and ovaries produce bone-replenishing hormones; without them the inevitable complication of early osteoporosis occurs unless lifelong hormones are prescribed. Only after the 1960s did modern endocrinology and urologic surgery evolve to allow efficient creative use of sex surgery, hormones, and enzymes for intersex babies.1 By this time penile primacy was well established in medicine. The external (visible) penis indicated to physicians how an infant with variant genitals could or would later cope. Too small a penis or too large a clitoris were considered incompatible with health and happiness. So a boy with micropenis and intersex babies were "reconstructed," all to be raised as girls because a functioning vagina could now be made surgically, but as yet a satisfactory adult penis could not. A small number of adult men with micropenis state they and partners are satisfied with the penis unaltered.

In Santayana's words, "those who ignore the past are condemned to repeat it." The historic records of 100 years ago of no intervention are carefully documented by this meticulous author and merit study. Today, clitoris reduction, childhood vaginoplasty that soon scleroses, selective deception of parents, cosmetic hypospadias repairs that cause more harm than help, and inadequate information about surgery are being questioned by adult intersexuals. They complain of violation of their rights to refuse surgery as infants 30 to 40 years ago. The Intersex Society of North America (ISNA; see accompanying review) protests "paternalistic" treatment by intersex physicians who tried to alter them medically or surgically without their consent, so that they could adjust to society. They seek acceptance by society as they are with no "abnormal" label, but rather as simply different, unless survival is in question.

What is the current approach to the child or adult newly diagnosed as intersex? The workup is sophisticated and expensive. As for management, will there be return to 1890 or to 1960? Or can there be a newer, more honest plan with detailed education and discussion of possible intersex treatments, outcomes, and complications? The intersex Web site is available but may be overwhelming for some. A decision to remain as is or to seek sex change will still require flexibility from all involved, amid doubts, anxieties, positives, and negatives. Physicians now have more information and experience; minimum risk with maximum gain for the patient is a medical principle that still must prevail—there may be no perfect solution. Confidentiality is different from secrecy, and lying to a patient is never helpful. A copy of the records can be given to parents to be kept in trust for their child until age 13 years so that they can know their history. But how accepting is society? Peers can be brutal in their curiosity and ridicule. All involved will seek the dream of happiness. "Good enough" results with or without hormones or surgery may be the best that is possible. Ongoing counseling, whether from family, friends, pastor, counselor, or other intersex persons will provide solid support, gender formation, and self-understanding on the climb toward self-acceptance, maturity, and an optimum life adjustment.

To read this book is to become aware of the tremendous complexity of human sexuality and gender identity—beyond genitals, hormones, enzymes, and even chromosomes and genes. Behavior, feelings, and values blend with intellect and how each individual is sexually drawn to another.

Domeena C. Renshaw, MD
Loyola University Medical Center
Maywood, Ill

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