Sarah Tabatabaei, Class of 2023
Medicalization is the process through which conditions come to be defined and treated as medical pathologies. Frequently intersex children, those born with ambiguous genitals, receive prompt medical treatments in order to refine a child’s sex to fit into a dichotomous binary that persists within society. Historically, ambiguous genitalia has been interpreted to challenge the rigid binary structure that exists between males and females. Claire Ainsworth reveals the extent of cultural influence on the construction of sex, stating, “Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner. But when it comes to sex, there is still intense social pressure to conform to the binary model” (Ainsworth 2015).
Pressure exists within medical efforts to limit the natural variance among children born with ambiguous genitalia. Treatments include but are not limited to hormonal treatment, surgical modifications of the genitals, and transformation therapy. In 2017, Human Rights Watch (HRW) called on the American Medical Association to ban medically unnecessary, irreversible, and often traumatizing surgeries on intersex babies (Knight 2018). This initiated a step in a direction where treatment protocol combines basic medical and ethical principles with less grave implications.
To sustain reform, multidisciplinary teams must be formed to properly approach the birth of a mixed-sex child. Although treatment of patients may require surgical considerations, concerns arise due to the lingering effects of outdated medical practices. To ensure an ethical, transparent, and appropriate treatment, a team of physicians, surgeons, psychologists, trained peer support, and therapists should devise a supportive management team. Multidisciplinary teams create an indiscriminate atmosphere that provides personalized care and extends management to both patients and their families that extends into a child’s adulthood.
The process of medicalization began with the efforts of John Money, a psychologist and sexologist who believed after 18 months postpartum, genes identified as malleable, meaning ambiguous genitalia could be assigned to “female or male”. He postulated that if parents of intersex children raised their child according to this assignment, the transition would be successful (Fausto-Sterling 2013). Until very recently, medical professionals have utilized Money’s theories to “treat” intersex “conditions”. Historically, Money and similar professionals focus on the genitalia of intersex babies, believing that socialization and phallic fate defined a child’s future. Though Money’s theory lacks proper evidence, it has been historically accepted because of theoreticians’ prestige and credibility over medical data/guidelines. If a gender assignment is later disclaimed by a child, physician credibility is weakened, thus changes have been made irreversible, decisive, and unambiguous.
Though remains of history exist in current practices, by the 1990s there was an increasing awareness of the mismanagement of individuals with intersex conditions. The story of two monozygotic twins, John and Joan, entered the media and revolutionized medical ethics. One of the twins experienced an accident during a circumcision that led to the destruction of the phallus. Though exposed to prenatal testosterone, the child was then raised as a girl. Money assumed that the influence of socialization as a female would allow the child to grow as a happy woman though, in fact, the child rebelled against being a girl by later transitioning gender to that of a male (Breedlove 2017). This instance removed credibility from medical practices and challenges the impact of postnatal modifications.
In the instance where intersex variability is discovered immediately postpartum, medicalization begins as soon as possible. Diagnosis is achieved through “assessing the chromosomal sex... and may include medical procedures such as cytologic screening; chromosomal analysis; assessing serum electrolytes; hormone, gonadotropin, and steroids evaluation; digital examination; and radiographic genitograph.” (Kessler 1990). Depending on whether the child is XY or XX, a decision is made whether to test the ability of the phallic tissue to respond to (HCG) androgen treatment. Phallus response is monitored and frequently measured using a phallometer. This process between diagnosis and assigning a male or female gender on a child is referred to as “normalization” in critical literature.
Kessler details normalization revealing 4 frequently apparent steps. The first step is that physicians teach parents about fetal development and that all fetuses have the potential to be male or female. Physicians “then stress the normalcy of the infant in other aspects” as if the intersex is just a mild defect like a mole, ensuring they avoid terms like “abnormal” and “disorder” (Kessler 1990). Thirdly, they initially emphasize that it is not the gender of the child that is ambiguous but it is the genitals (“maldeveloped organs”). Finally, physicians teach parents that social factors, which parents and communities help construct, are more important in gender development than biological factors (Kessler 1990).
Current advocacy, including the HRW, has recognized the lingering remains of medicalization and normalization practices by devising plans for structural reform. In order to create an ethical, inclusive, and respectful treatment, multidisciplinary teams must be formed within a hospital, office, and counseling networking. Following diagnosis, multidisciplinary teams offer subsequent management of patients and their families with effective communication among disciplines that extends into a child’s adulthood. Disciplines include “centres of expertise for DSDs that include physicians, surgeons, psychologists and specialists in diagnostic procedures to manage patients and their families… [and] the inclusion of trained peer support” (Hiort et. al 2014). Intersex variance should not be viewed as medical emergencies and surgery should be performed to save a life or dramatically improve it. Multidisciplinary teams would ensure a child’s future autonomy is preserved through non-irreversible treatments, and parents will have full access to information of said treatments and medical measures.
Preceding the implementation of multidisciplinary teams, it must be understood that gender is a spectrum and that dimorphism disintegrates at the level of basic biology. With an understanding of the natural existence of gender beyond a rigid binary, society is a step closer to ethical and optimal support for intersex children and their families.
Works Cited
Ainsworth, Claire. "Sex Redefined." Nature, vol. 518, 19 Feb. 2015, pp. 288-91.
Ameen, M. Baby Feet. 5 June 2015. Pixabay, Adobe Stock, 17 July 2015.
Breedlove, S Marc. "Prenatal Influences on Human Sexual Orientation: Expectations versus Data." Archives of Sexual Behavior 46 (2017): 1583-1592.
Fausto-Sterling, Anne. "The Five Sexes, Revisited." The Sciences, 13 July 2013, pp. 18-23.
Hiort, Olaf et al. "Management of disorders of sex development." Nature Reviews Endocrinology 10 (2014): 520-529.
Kessler, Suzanne J. "The Medical Construction of Gender: Case Management of Intersexed Infants." The University of Chicago Press, vol. 16, 1990, pp. 3-26.
Knight, Kyle. "Medical Experts Call to Defer Unnecessary Intersex Surgeries." Human Rights Watch, Oct. 2018.
Pressure exists within medical efforts to limit the natural variance among children born with ambiguous genitalia. Treatments include but are not limited to hormonal treatment, surgical modifications of the genitals, and transformation therapy. In 2017, Human Rights Watch (HRW) called on the American Medical Association to ban medically unnecessary, irreversible, and often traumatizing surgeries on intersex babies (Knight 2018). This initiated a step in a direction where treatment protocol combines basic medical and ethical principles with less grave implications.
To sustain reform, multidisciplinary teams must be formed to properly approach the birth of a mixed-sex child. Although treatment of patients may require surgical considerations, concerns arise due to the lingering effects of outdated medical practices. To ensure an ethical, transparent, and appropriate treatment, a team of physicians, surgeons, psychologists, trained peer support, and therapists should devise a supportive management team. Multidisciplinary teams create an indiscriminate atmosphere that provides personalized care and extends management to both patients and their families that extends into a child’s adulthood.
The process of medicalization began with the efforts of John Money, a psychologist and sexologist who believed after 18 months postpartum, genes identified as malleable, meaning ambiguous genitalia could be assigned to “female or male”. He postulated that if parents of intersex children raised their child according to this assignment, the transition would be successful (Fausto-Sterling 2013). Until very recently, medical professionals have utilized Money’s theories to “treat” intersex “conditions”. Historically, Money and similar professionals focus on the genitalia of intersex babies, believing that socialization and phallic fate defined a child’s future. Though Money’s theory lacks proper evidence, it has been historically accepted because of theoreticians’ prestige and credibility over medical data/guidelines. If a gender assignment is later disclaimed by a child, physician credibility is weakened, thus changes have been made irreversible, decisive, and unambiguous.
Though remains of history exist in current practices, by the 1990s there was an increasing awareness of the mismanagement of individuals with intersex conditions. The story of two monozygotic twins, John and Joan, entered the media and revolutionized medical ethics. One of the twins experienced an accident during a circumcision that led to the destruction of the phallus. Though exposed to prenatal testosterone, the child was then raised as a girl. Money assumed that the influence of socialization as a female would allow the child to grow as a happy woman though, in fact, the child rebelled against being a girl by later transitioning gender to that of a male (Breedlove 2017). This instance removed credibility from medical practices and challenges the impact of postnatal modifications.
In the instance where intersex variability is discovered immediately postpartum, medicalization begins as soon as possible. Diagnosis is achieved through “assessing the chromosomal sex... and may include medical procedures such as cytologic screening; chromosomal analysis; assessing serum electrolytes; hormone, gonadotropin, and steroids evaluation; digital examination; and radiographic genitograph.” (Kessler 1990). Depending on whether the child is XY or XX, a decision is made whether to test the ability of the phallic tissue to respond to (HCG) androgen treatment. Phallus response is monitored and frequently measured using a phallometer. This process between diagnosis and assigning a male or female gender on a child is referred to as “normalization” in critical literature.
Kessler details normalization revealing 4 frequently apparent steps. The first step is that physicians teach parents about fetal development and that all fetuses have the potential to be male or female. Physicians “then stress the normalcy of the infant in other aspects” as if the intersex is just a mild defect like a mole, ensuring they avoid terms like “abnormal” and “disorder” (Kessler 1990). Thirdly, they initially emphasize that it is not the gender of the child that is ambiguous but it is the genitals (“maldeveloped organs”). Finally, physicians teach parents that social factors, which parents and communities help construct, are more important in gender development than biological factors (Kessler 1990).
Current advocacy, including the HRW, has recognized the lingering remains of medicalization and normalization practices by devising plans for structural reform. In order to create an ethical, inclusive, and respectful treatment, multidisciplinary teams must be formed within a hospital, office, and counseling networking. Following diagnosis, multidisciplinary teams offer subsequent management of patients and their families with effective communication among disciplines that extends into a child’s adulthood. Disciplines include “centres of expertise for DSDs that include physicians, surgeons, psychologists and specialists in diagnostic procedures to manage patients and their families… [and] the inclusion of trained peer support” (Hiort et. al 2014). Intersex variance should not be viewed as medical emergencies and surgery should be performed to save a life or dramatically improve it. Multidisciplinary teams would ensure a child’s future autonomy is preserved through non-irreversible treatments, and parents will have full access to information of said treatments and medical measures.
Preceding the implementation of multidisciplinary teams, it must be understood that gender is a spectrum and that dimorphism disintegrates at the level of basic biology. With an understanding of the natural existence of gender beyond a rigid binary, society is a step closer to ethical and optimal support for intersex children and their families.
Works Cited
Ainsworth, Claire. "Sex Redefined." Nature, vol. 518, 19 Feb. 2015, pp. 288-91.
Ameen, M. Baby Feet. 5 June 2015. Pixabay, Adobe Stock, 17 July 2015.
Breedlove, S Marc. "Prenatal Influences on Human Sexual Orientation: Expectations versus Data." Archives of Sexual Behavior 46 (2017): 1583-1592.
Fausto-Sterling, Anne. "The Five Sexes, Revisited." The Sciences, 13 July 2013, pp. 18-23.
Hiort, Olaf et al. "Management of disorders of sex development." Nature Reviews Endocrinology 10 (2014): 520-529.
Kessler, Suzanne J. "The Medical Construction of Gender: Case Management of Intersexed Infants." The University of Chicago Press, vol. 16, 1990, pp. 3-26.
Knight, Kyle. "Medical Experts Call to Defer Unnecessary Intersex Surgeries." Human Rights Watch, Oct. 2018.
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