publié en francais en 2013, avec une préface de pascale molinier. (il n'y a ni préface ni le texte revisté)
VERSION FRANCAISE ET ANGLAISE
Anne fausto sterling , The five sexes : why male and
female are not enough, the sciences, mars-avril 1993, p20-24 traduit de l’anglais par anne-emmanuelle
BOTERF
1843, Salisbury (Connecticut) : Levy Suydam,
vingt-trois ans, demande aux conseillers municipaux de la ville de prendre en
compte son vote en faveur du parti whig
lors des élections locales très disputées. Cette requête soulève de nombreuses
objections parmi l’opposition, et ce, pour des raisons qu’on trouve rarement
évoquées dans les annales de la démocratie américaine : Suydam serait
moins un homme que femme : donc –le droit de vote ne sera accordé aux
femmes de quatre vingt ans, plus tard- il ne peut pas prendre part au scrutin.
Pour mettre fin aux discussions, on demande a un certain William James Barry,
médecin, d’examiner Suydam. On présume qu’il rencontre un pénis, car le bon
docteur déclare que le votant potentiel est bien un homme. Suydam ayant rejoins
sain et sauf leurs rangs, les whigs remportent les élections avec une voix
d’avance.
Le diagnostic du docteur Barry va pourtant se révéler un peu prématuré.
Quelques jours plus tard, en effet, il découvrit nonobstant le pénis, Suydam avait des menstruations
régulières et possédait une ouverture vaginale. Ses prédispositions physiques
et mentales étaient plus complexes qu’on ne le suspectait. Il/elle avait les
épaules étroites, les hanches assez larges et il lui arrivait d’être attiré(e)
sexuellement par les femmes. Le docteur Barry écrira plus
tard : »beaucoup de gens ont remarqué les penchant féminin [de
Suydam] tels que la passion pour les couleurs gaies, les tissus, le patchwork,
ainsi que son aversion et son manque d’aptitude pour le travail physique.» nous
ne savons pas clairement si le vote de Suydam fut finalement accepté ou refusé,
ni si le résultat des élections s’en est trouvé modifié par la suite. L’idée
qu’il n’existe que deux sexes est profondément ancrée dans la culture
occidentale. La langue elle-même refuse toute autre possibilité. Pour raconter
l’histoire de Suydam Levi, j’ai donc dû inventer de nouvelles conventions
–il/elle,- (e) pour les adjectifs et les participes passés-pour désigner
quelqu’un qui, à l’évidence, n’est ni mâle ni femelle, ou bien peut être les
deux a la fois. De même, au regard de la loi, tout adulte est soit un homme
soit une femme et la différence, bien entendu, est loin d’être anodine. Dans le
cas de Suydam, c’est son droit de vote qui était en jeu. Aujourd’hui, de là
signifie être obligé€ de faire son service militaire ou en être exempté, mais
aussi être sous la coupe de certaines lois concernant le mariage, la famille ou
l’intimité de chacun. Dan de nombreux états américains, par exemple, deux
hommes inscrits comme tels sur les registres ne peuvent avoir de relations
sexuelles ensemble sans enfreindre les lois-antisodomie.
Mais
si l’état et le système juridique trouvent leur intérêt dan le maintiens d’un
système sexuel bicatégorisé, ils sont contre nature. En effet, d’un point de
vue biologique, il existe de nombreuses
gradations entre la femelle t le mâle ! Critères varient selon les
personnes, mais certaines affirment que le long de ce spectre, on trouve au
moins cinq sexes –et peut être même plus.
Pendant
un temps, des médecins chercheurs ont reconnu le concept de corps intersexe.
Dans les manuels de médecine, le terme
« intersexuation » est en revanche utilisé pour évoqué l’ensemble des
trois sous catégories principales : les hermaphrodites
« veritables », que j’appelle les « herms », qui possèdent
un testicule et un ovaire (les organes reproducteurs de spermatozoïde et
d’ovules, aussi appelé gonades) ; les pseudo-hermaphrodites masculins (les
« merms »), qui possèdent des testicules et certains aspects de
l’appareils génitales féminin, mais pas d’ovaires : et les
pseudo-hermaphrodites féminin (les « ferms »), qui possèdent des
ovaires et certains aspects de l’appareils masculin, mais pas de testicules.
Chacune de ces catégories est en elle-même très complexe : le pourcentage
de caractéristiques mâles et femelles, par exemple, peut varier énormément
selon l’individu d’un même sous-groupe. De plus, la vie intime de ces personnes
(besoins particuliers, problèmes, attraits et dégouts) n’a jamais été explorée
par les scientifiques. En e fondant sur ce qui est connu d’eux, je suggère
néanmoins que ces trois intersexes –herms, merms, ferms- méritent d’être pris
en considération comme des variantes sexuelles supplémentaires. J’irais
d’ailleurs plus loin en affirmant que pour moi, le sexe est un continuum modulable à l’infini qui ne tient pas compte
des contraintes imposées par les catégories, fussent-elles au nombre de cinq.
Il est extrêmement difficile d’estimer la fréquence de
l’intersexuation, et encore plus a déterminer a laquelle des trois catégories
appartiennent les intéressé(e)s. ce manque d’information n’est pas très
surprenant puisque ce n’est pas le genre de détail qu’ils/elles écrivent sur
leur CV ! Le psychologue John money (Johns Hopkins university), un
spécialiste de l’étude des défauts congénitaux des organes sexuels, suggère que
les intersexes constitueraient au moins 4% des naissances. Comme je le fais
remarquer a mes étudiants de l’université de Brown, ce rapport, sil est exact,
implique que, parmi les 6 mille étudiants de notre campus, environ 240 seraient
intersexes –soit bien assez pour former une minorité non négligeable.
En
réalité, seul(e)s quelques étudiant(e)s auraient pu arriver jusqu’à l’université
en ayant conservé leur ambigüité génitales. Les dernières avancées en
physiologie et en technologie chirurgicale permettent désormais aux médecins de
repérer les intersexes des la naissance. Ces tout-petits suivent presque
immédiatement un traitement chirurgicale t hormonal de façon a s’intégrer
« normalement » dan la société, comme n’importe quel mâle ou femelle hétérosexuel(le). Je
tiens à préciser qu’aucune conspiration ne vient motiver ces décisions. Les
objectifs sont purement humanitaires et reflètent le souhait de voir ces
personnes « s’intégrer », aussi bien physiquement que
psychologiquement. Les préjugés qu’un tel souhait peut dissimuler n’ont en
revanche pratiquement pas été étudié par
la communauté médicales –l’idée qu’il ne peut y avoir que deux sexes,
que seule l’hétérosexualité est normale, qu’il existe un modèle a suivre en
matière de santé psychologique…
Le mot « hermaphrodite
« vient des noms grecs hermès, connu pour être le messager des dieux, le
patron de la musique, le contrôleur des rêves ou encore le protecteur des
animaux, et Aphrodite, déesse de l’amour sexuel et de la beauté. Selon la
mythologie grecque, de l’union de ces dieux est né hermaphrodite qui, a l’âge
de quinze ans, devint moitié male, moitié femelle, après que son corps a
fusionné avec celui d’une nymphe dont il était tombé amoureux. Chez certains
hermaphrodite « veritable, les testicules et les ovaires se développe
séparément mais de manière bilatérale, tandis que chez d’autres, ils grandissent pour ne former
qu’un seul organe : ovotesticule. Il n’est pas rare qu’au moins l’une des
deux gonades fonctionne correctement et produise des spermatozoïdes ou des
ovules, ainsi que des taux d’hormones sexuelles suffisantes (androgènes et
œstrogènes). En théorie, il devrait être possible pour un hermaphrodite de
devenir a la fois le père et la mère d’un enfant, mais en pratique, la
disposition des canaux internes ne permets pas la rencontre du sperme et des
ovules.
Contrairement aux hermaphrodites « veritables », les
pseudo-hermaphrodites possèdent deux gonades de même type et un caryotype
normal féminin (XX) ou masculin (XY). Leur particularité est que leur appareil
génital externe et leurs caractères secondaires ne coïncident pas avec les chromosomes.
Ainsi, les merms ont des testicules couples aux chromosomes XY, mais également
un vagin et un clitoris ; leur poitrine se développe généralement a la
puberté. En revanche, ils/elles n’ont pas de menstruations. Les ferms ont des
ovaires, deux chromosomes X et parfois un utérus, mais également une partie de
l’appareil génital masculin externe. En l’absence d’intervention chirurgicale,
à la puberté, il se peut que leur barbe commence a pousser, que leur voix mue
et que leur pénis atteigne une taille adulte. La variété d’anatomie sexuelle
rencontrée lors des examens cliniques qui sont si nombreuses qu’aucun système
de classement ne pourrait les prendre intégralement en compte. En 1969, par
exemple, deux chercheurs français, Paul Guinet de la clinique endocrinologique
de Lyon et jacques Decourt de la clinique endocrinologique de paris, ont
rencontre 98 cas d’hermaphrodisme « véritable » -soit personne
possédant a la fois les tissus testiculaire et ovarien- en se référant
uniquement a l’aspect de l’appareil génital externes et a leurs canaux
internes ? Dans certain cas, es sujets présentaient un développement
féminin très avancé. Ils/elles avaient deux ouvertures distinctes pour le vagin
et l’urètre, une vulve entourée de petites et de grandes lèvres (lèvres
vaginales), leur poitrine se développait à la puberté et ils/elles commençaient
en général a avoir leurs menstruations. La taille de leur clitoris, son
comportement lors de l’excitation sexuelle et, à la puberté, la menace parfois
qu’il se transforme en pénis, les poussait a consulter un médecin. Dans un
autre groupe, les sujets savaient aussi de la poitrine, un corps efféminé et
des menstruations. En revanche, leurs lèvres vaginales, plus ou moins reliées
entre elles, formaient un scrotum incomplet. Le phallus (ici, terme
embryologique pour la structure qui deviendra, lors d’un développement normal,
un clitoris ou un pénis) mesurait entre 3,8 et 7,1 centimètres ; la
miction se faisait néanmoins par un urètre qui s’ouvrait a l’intérieur ou a
proximité du vagin.
La majorité (55%) des hermaphrodites « veritables rencontrés
par Guinet et Decourt avaient un physique plutôt masculin. Chez ces personnes,
l’urètre se trouve à l’intérieur ou a proximité du phallus, ce dernier
ressemblant plus a un pénis qu’a un clitoris, et l’évacuation du sang menstruel
se fait au moment de la miction. Cependant, malgré l’apparence masculine de
l’appareil génital, la poitrine se développe a la puberté. Il est possible
qu’un échantillon de plus de 98 hermaphrodites « véritables » révèle
encore plus de contrastes et de subtilités. Je me contenterai de dire que les
variations sont telles que seule une opération chirurgical permet de savoir
quelles parties sont présentes et ce a quoi elles sont rattachées.
Les origines embryologiques des hermaphrodites humains corroborent les
connaissances du développement sexuel mâle et femelle. Au stade embryonnaire,
la gonade choisit en général assez tôt de suivre un développement sexuel male
ou femelle. Les gonades mixtes (ovotesticules) ne choisissent pas entre les
deux. E la même façon, le phallus embryonnaire devient la plupart du temps un
pénis ou un clitoris, mais l’existence de stades intermédiaires de
développement n’est en rien un surprise pour l’embryologue. Chez l’embryon, les
structures urogénitales s’épaississent puis s’ouvrent pour devenir les lèvres
vaginales, ou fusionnent pour former un scrotum. Chez certains hermaphrodites,
le choix entre ouverture et fermeture reste ambivalent. Les embryons de
mammifères possèdent donc toutes les structures nécessaires à la construction
de l’utérus femelle et des trompes de Fallope, mais aussi les structures qui
pourront constituer en partie le système reproducteur male. En règle générale,
les voies génitales internes –mâles ou femelles –disparaissent partiellement et
les structurent restantes achèvent le développement du futur sexe approprié.
Chez les hermaphrodites, les deux appareils génitaux se développent de façon
variable.
L’intersexuation n’est pas un phénomène récent. Par exemple,
les hermaphrodites apparaissent déjà dans les récits des origines de l’homme.
Les premiers exégètes de la bible pensaient qu’Adam était au départ
hermaphrodite, puis s’est divisé en deux personnes –un mâle et une femelle-
après avoir péché. Selon Platon, il fut un temps où trois sexes coexistaient
–mâle, femelle et hermaphrodite-, mais la troisième aurait disparu avec le
temps.
Les deux livres regroupant les lois juives, le talmud et la tosefta,
comportent de longues listes de réglementations destinées aux personnes de sexe
mixte. La tosefta interdit formellement aux hermaphrodites d’hériter du
patrimoine de leur père (comme les filles), de s’isoler avec des femmes (comme
les fils), ou de se raser (comme les hommes). Quand les hermaphrodites ont
leurs menstruations, ils/elles doivent se tenir a l’écart des hommes (comme les
femmes). Il leur est impossible d’offrir leur témoignage ou de devenir prêtres
(comme les femmes), mais ils/elles ont néanmoins concerné(e)s par les lois de
la pédérastie.
En Europe, de nouveaux modèles sont apparus a la fin du moyen âge qui
ont d’une certaine manière perduré jusqu'à aujourd’hui : les
hermaphrodites devait choisir entre l’un des deux rôles du genre et s’y tenir.
En cas de transgression, la sanction était souvent la mort. Ainsi, au XVIIe
siècle, un hermaphrodite écossais qui vivait comme femme fut enterré(e)
vivant(e) après avoir eu des rapports avec la fille de son maitre.
Pour toutes les questions d’héritages, de légitimité, de paternité, de
succession des titres de noblesse ou d’éligibilité a certaines professions, les
systèmes juridiques anglo-saxons modernes exigent qu’au moment de la
déclaration de naissance, soit de sexe male, soit de sexe femelle. Aujourd’hui,
aux Etats-Unis, ce sont les lois de chaque état qui régissent la détermination
du sexe. En Illinois, les adultes ont le droit de modifier le sexe inscrit sur
leur acte de naissance, à condition qu’un médecin atteste avoir pratiqué l’opération
chirurgicale appropriée. L’académie new-yorkaise de médecine, quant a elle,
adopté une position diamétralement opposé : en 1966, elle a en effet
défendu l’idée que, malgré une opération chirurgicale ayant modifié l’appareil
génital externe, les chromosomes sexuels restaient les même. Cette mesure favorise l’intérêt général dans
le cadre de la lutte anti-fraude au détriment de la volonté de la personne qui
souhaiterait cacher son sexe d’origine.
Au
XXe siècle, la communauté médicale a achevé le travail entamé par les juristes,
soit l’éradication complète de toute forme incarnée de sexe non conforme à un
schéma mâle-femelle hétérosexuel(le). Assez ironiquement, ce sont nos
connaissances plus sophistiquées de la complexité des systèmes sexuels qui ont
mené à la répression de cette complexité.
En 1937, l’urologue Hugh H. Young, professeur à la Johns Hopkins
university, a publié un livre intitulé « genital abnormalities, hermaphrodites and related adrenal disease ».
L’ouvrage est remarquable d’érudition, de perspicacité scientifique et
d’ouverture d’esprit. Young y a rassemblé de nombreux récits de cas
soigneusement documentés avec l’intention d’étudier et de décrire le traitement
médical de ces « accidents de naissance ». Il étudia ces intersexes sans les juger ni les forcer à
suivre un traitement qu’ils refusaient. Il a également fait preuve d’une rare
impartialité en appelant celles/ceux dont les expériences sexuelles étaient
aussi bien féminines que masculines des « hermaphrodites
pratiquants ».
L’un
des cas les plus intéressants étudiés par Young était celui d’Emma, un
hermaphrodite ayant grandi en tant que femelle. Emma était à la fois doté(e)
d’un vagin, d’un clitoris de la taille d’un pénis, ce qui lui permettait
d’avoir des relations hétérosexuelles « normales » avec des hommes
comme avec des femmes. Encore adolescent(e), Emma a eu un certain nombre de
relations sexuelles avec des filles envers qui il/elle ressentait une profonde
attraction. A dix-neuf ans, il/elle s’est marié(e) avec un homme.
Malheureusement, comme celui-ci ne le/la satisfait pas sexuellement (alors que
lui -même ne s’en ai jamais plaint), Emma a gardé des amantes tout au long de
ce mariage et des suivants. Assez fréquemment, il/elle avait des relations
sexuelles et du plaisirs avec elles. Young décrit son sujet comme une personne
« assez satisfaite et même plutôt heureuse. ». Lors de leurs
discussions, il est arrivé qu’Emma lui avoue qu’il/elle préférerait être un homme,
ce à quoi il lui répondait qu’il était relativement facile de changer de sexe.
La réaction d’Emma est effrayante d’égoïsme : « est ce qu’il faudra
retirer ce vagin ? Je ne suis pas sûr(e) d’en avoir envie parce que c’est
ce qui me fait vivre. Si vous l’enleviez, je serais obligé(e) de quitter mon
mari et de travailler, donc je préfère le garder et rester comme je suis. Mon
mari gagne bien sa vie, et même si je n’ai aucun plaisir au lit avec lui, je me
rattrape largement avec mes amantes. »
Pourtant, tout en expliquant l’intersexuation à la lumière
de la raison scientifique, Young en entamais la suppression. Son livre est en
effet un long traité sur les dernières méthodes chirurgicales et hormonales en
matière de transformation des intersexes en males ou en femelles. Si Yung
pouvait paraîtres différent de ces successeurs par son absence de jugement et
la liberté qu’il laissait a ses patients et a leurs familles, il a néanmoins
renforcé les fondations sur les quelles les pratiques d’interventions actuelles
ont été bâtis.
En 1969, année ou les médecins anglais Christopher J.
DEWHURST et Ronald R GORDON ont écrit THE intersexual disorders, les approches
médicales et chirurgicales de l intersexuation voisinait déjà avec le stade le
l’uniformité rigide. Il ‘ est pas vraiment surprenant de voir que les opinions
ce sont durcis en ces temps de mythiques féminine- juste après la 2nd
guerre mondial l’afflue vers les banlieues et la divisions des rôles de la
familles en fonction du sexe de chacun . le fait que le consensus médicale
ne soit pas universel ( ou qu’il semble prêt a éclaté de nouveau) ce ressent dans le ton quasi
hystérique qu’ emploi DEWHURST et GORDON dans leurs livres, bien loin des
explications calmes et raisonnable trouver dans le travail fondateur de Young.
Prenez par exemples cette première description d’un nouveau né
intersexe : « vous ne pouvez qu’imaginer l’angoisse des parents.
Qu’une déformation, chez le nouveau né, […] affect une question si
fondamentale, à savoir le sexe de l enfant […] est un événement tragique. Les
parents voient immédiatement en leurs progéniture un inadapté incapable
d’intégration social, voué a vivre dans l isolement et la frustration, comme
tout être anormal. »
Pour DEWHURST et Gordon, un tel destin serais e effet le lot
réservé aux bébés dont le problème n’est pas traiter correctement « fort
heureusement, écrivent-ils, en cas d’opération réussis, l’aspect externe seras
considérablement amélioré, bien plus que n’ aurais pus l’espérer les pauvres
parents- que l’événement auras bouleverser- ou toute autres personne ignorant
l’ existence de ces solutions. »
Les dogmes scientifiques c’est vite rallié à l’idée que les
hermaphrodites qui ne serraient pas soignés médicalement sont voués à une vie
misérable. Il existe pourtant peu de recherches empiriques su le sujet
permettent de renforcé cette hypothèse ; certaines données récolté dans le
but de défendre la systématisation des traitements médicaux sont mêmes venues
la contredire. Francis BENTON, lui/elle aussi hermaphrodite pratiquant
suivis(e) par Young, « ne c’était jamais inquiété(e) de sa situation
ne voulais pas que celle-ci change et profitais de la vie » c’est
également discourt d’Emma, notre opportuniste femme au foyer. DEWHURST et
Gordon eux même, pourtant convaincus de l’importance psychologique du
traitement des intersexes dès leurs plus jeunes âges on reconnues avoir puent
« changer de sexe » de patients plus âges, avec grands succès. Ce
référent à vingt cas d’enfants opérés après l’âge supposé fatidique de 18 mois,
ils ont déclaré que tous ces changements de sexes avaient été « une
réussite », en venant a ce demandé si la réinscription dans les registres
ne devrais pas « êtres plus facilement recommandé jusqu’ [alors]. »Le
traitement de l’intersexuation au siècle dernier offre un bel exemple de ce qui
Michel FOUCAULT appelle le bio pourvoir les connaissances acquises en biochimie
en embryologie, endocrinologie, en psychologie et en chirurgie ont permis aux
médecins de contrôler le sexe même de l’être humain. Un examen minutieux est
nécessaire, tant les contradictions sont nombreuses avec ce type de pouvoir.
D’un côté, la « prise en main » médicale de l’intersexuation s’est
certainement développé grâce a la volonté de libérer les gens de leur douleurs
psychologique telle que perçue par
l’extérieur (impossible de savoir ici s’il s’agit de la douleur du patient, de
ses parents ou du médecin). Ainsi, si l’on part du principe que dans une
société bicatégorisé, les gens ne peuvent être vraiment heureux et productifs
qu’a condition d’être certains d’appartenir a l’un des deux sexes reconnus,
alors la médecine moderne a parfaitement atteint son objectif.
D’un
autre côté, ces mêmes avancées médicales peuvent être considérées, non pas
comme un progrès, mais comme une sorte de discipline. Le corps des
hermaphrodites est indiscipliné. Il n’intègre pas naturellement une classification
binaire ; seule une opération chirurgicale peut les faire entrer. Mais en
quoi est ce un problème si une « femme » -c'est-à-dire une personne
avec une poitrine, un vagin, un utérus, des ovaires et des menstruations-
possède aussi un clitoris suffisamment grand pour pénétrer le vagin d’une autre
femme ? En quoi est un problème si le bagage biologique de certaines
personnes leur permet d’avoir « naturellement » des relations
sexuelles aussi bien avec des hommes qu’avec des femmes ? Les réponses résident
apparemment dans note besoins culturelles de maintenir la distinction claire
entre es sexes. La société rend obligatoire le contrôle des corps intersexe
parce qu’ils estompent et ignorent cette grande division. Etant données que les
hermaphrodite incorpore littéralement les deux sexes, ils défient les croyances
traditionnelles concernant la différence sexuelle : ils possèdent la
capacité agaçante de vivre un temps comme une femme, un temps comme un homme,
et brandissent le spectre de l’homosexualité. Et si les choses étaient tout a
fait différentes ? Imaginer un monde dans lequel les connaissances
médicales ayant permis la normalisation des patients intersexes seraient cette
fois mise au service de multiple sexualité. Imaginez que les sexes se soient
multipliés a l’extrême, sans limite a l’imagination. Ce serait un monde de
pouvoir partagé. Patients et médecins, parents et enfants, male et femelle,
hétérosexuelle et homosexuelle : toutes ses oppositions, et bien d’autres
encore, devraient être dissoute, car source de division. Une nouvelle
éthique émergerait en matière de
traitements médicaux, laissant place à l’ambigüité dans une culture qui aurait
dépassé la division sexuelle. La principale mission de ces traitements serait
donc la préservation de la vie. Ils concerneraient les hermaphrodites, non pas
pour les rendre conformes a la société, mais a cause des éventuelles maladies
graves –hernies, tumeurs des gonades, taux de sodium anormal dû à un
dysfonctionnement des glandes surrénales- qui accompagnent parfois le
développement hermaphrodite. Dans ce monde idéal, les interventions médicales
sur les intersexes seraient très rares avant sept ans. Par la suite, le
traitement serait défini grâce à une étroite collaboration entre le patient, le
médecin et d’autres conseillers spécialisés dans les questions de multiplicité
des genres. Je mentirais en affirmant que la transition vers mon utopie se fera
en douceur. Le sexe, même celui qu’on suppose « normal », de type
hétérosexuel, continu de créer des inquiétudes non dites dans la société occidentale. Il semble
évident qu’une culture qui doit déjà résoudre –d’un point de vue religieux,
mais aussi, dans certains états états-uniens, juridique- le problème de
l’homosexualité, qui est une réalité pourtant très ancienne et sans
complication, n’est sans doute pas prête à accepter facilement
l’intersexuation. La question la plus problématique sera sans doute celle de
l’éducation des enfants. Les parents, du moins depuis l’époque victorienne,
sont tracassés –allant parfois jusqu’au déni total- par le fait que leurs
enfants sont des êtres sexués. Tout cela explique largement pourquoi les
enfants intersexes sont généralement placés d’office dans l’une des deux
catégories sexuelles les plus répandues. Mais quelles seraient les conséquences
psychologiques d’un itinéraires alternatifs, à savoir élever ses enfants comme
des intersexes assumés ? À première vue, une telle entreprise parait vouée
à l’échec. Qu’arriverait-il par exemple à un (e) enfant intersexe dans la cruelle
arène de la cour de recréation ? Au moment de prendre sa douche après le
cour de sport, quelles horreurs, quelles humiliations devrait-il/elles subir
après avoir dévoilé son anatomie dans toute sa splendeur non
traditionnelle ? Est ce que l’enfant s’entraineraient avec les filles ou
avec les garçons ? Dans quelles toilettes irait-il/elle? Et comment son
papa et sa maman pourraient l’aider et le/la protéger tout au long de ce champ
de mines de la puberté ?
Au cours des trente dernières années, ces questions ont été
ignorées puisque l’ensemble de la communauté scientifique préférerait tourner
le dos a ce chemin alternatif vers une intersexuation libérée. Dans les
recherches les plus récentes, de nombreux cas, généralement recensés entre 1930
et 1960 (soit avant que l’intervention chirurgicale ne devienne endémique),
sont tout bonnement ignorés. Ces rapports décrivent tous, presque sans
exception, la croissance d’enfants qui se savaient intersexes (sans pour autant
s’en vanter) et qui s’adaptaient a leur statut inhabituel. Certaines de ces
études sont riches en détails – au point de retranscrire la douche qui suivait
les séances de sport, a laquelle la plupart des intersexes ne participaient
pas, sans que cela pose de problème. Dans tous les cas, aucun des enfants
suivis n’est devenu psychotique ou suicidaire.
Malgré cela, les nuances dans la socialisation des intersexes
mériteraient des analyses plus poussées et sophistiquées. En clair, avant que
ma vision d’une multiplicité sexuelle ne devienne réalité, les premiers enfants
ouvertement intersexes et leurs parents devront agir en pionniers et porter le
poids des blessures grandissantes de notre société. Mais sur le long terme –ce
qui pourrait prendre des générations- nous y gagnerons peut être une société où
la sexualité, au lieu d’être crainte ou tournée en dérision, sera célébrée pour
ses subtilités.
The Five Sexes: Why Male and Female Are Not Enough
By Anne Fausto-Sterling
The Sciences March/April 1993, p. 20-24
Anne Fausto-Sterling is Professor of Biology and Women's Studies in the Department of
Molecular and Cell Biology and Biochemistry at Brown University. Professor Fausto-
Sterling's new book, entitled Sexing the Body: Gender Politics and the Construction of
Sexuality, appeared in February, 2000.
In 1843 Levi Suydam, a twenty-three-year-old resident of Salisbury, Connecticut, asked
the town board of selectmen to validate his right to vote as a Whig in a hotly contested
local election. The request raised a flurry of objections from the opposition party, for
reasons that must be rare in the annals of American democracy: it was said that Suydam
was more female than male and thus (some eighty years before suffrage was extended to
women) could not be allowed to cast a ballot. To settle the dispute a physician, one
William James Barry, was brought in to examine Suydam. And, presumably upon
encountering a phallus, the good doctor declared the prospective voter male. With
Suydam safely in their column the Whigs won the election by a majority of one.
Barry's diagnosis, however, turned out to be somewhat premature. Within a few days he
discovered that, phallus notwithstanding, Suydam menstruated regularly and had a
vaginal opening. Both his/her physique and his/her mental predispositions were more
complex than was first suspected. S/he had narrow shoulders and broad hips and felt
occasional sexual yearnings for women. Suydam's "'feminine propensities, such as a
fondness for gay colors, for pieces of calico, comparing and placing them together, and an
aversion for bodily labor, and an inability to perform the same, were remarked by many,"
Barry later wrote. It is not clear whether Suydam lost or retained the vote, or whether the
election results were reversed.
Western culture is deeply committed to the idea that there are only two sexes. Even
language refuses other possibilities; thus to write about Levi Suydam I have had to invent
conventions-- s/he and his/her-- to denote someone who is clearly neither male nor
female or who is perhaps both sexes at once. Legally, too, every adult is either man or
woman, and the difference, of course, is not trivial. For Suydam it meant the franchise;
today it means being available for, or exempt from, draft registration, as well as being
subject, in various ways, to a number of laws governing marriage, the family and human
intimacy. In many parts of the United States, for instance, two people legally registered as
men cannot have sexual relations without violating anti-sodomy statutes.
But if the state and the legal system have an interest in maintaining a two-party sexual
system, they are in defiance of nature. For biologically speaking, there are many
gradations running from female to male; and depending on how one calls the shots, one
can argue that along that spectrum lie at least five sexes-- and perhaps even more.
For some time medical investigators have recognized the concept of the intersexual body.
But the standard medical literature uses the term intersex as a catch-all for three major
subgroups with some mixture of male and female characteristics: the so-called true
hermaphrodites, whom I call herms, who possess one testis and one ovary (the spermand
egg-producing vessels, or gonads); the male pseudohermaphrodites (the "merms"),
who have testes and some aspects of the female genitalia but no ovaries; and the female
pseudohermaphrodites (the "ferms"), who have ovaries and some aspects of the male
genitalia but lack testes. Each of those categories is in itself complex; the percentage of
male and female characteristics, for instance, can vary enormously among members of the
same subgroup. Moreover, the inner lives of the people in each subgroup-- their special
needs and their problems, attractions and repulsions-- have gone unexplored by science.
But on the basis of what is known about them I suggest that the three intersexes, herm,
merm and ferm, deserve to be considered additional sexes each in its own right. Indeed, I
would argue further that sex is a vast, infinitely malleable continuum that defies the
constraints of even five categories.
Not surprisingly, it is extremely difficult to estimate the frequency of intersexuality, much
less the frequency of each of the three additional sexes: it is not the sort of information
one volunteers on a job application. The psychologist John Money of Johns Hopkins
University, a specialist in the study of congenital sexual-organ defects, suggests
intersexuals may constitute as many as 4 percent of births. As I point out to my students
at Brown University, in a student body of about 6,000 that fraction, if correct, implies
there may be as many as 240 intersexuals on campus-- surely enough to form a minority
caucus of some kind.
In reality though, few such students would make it as far as Brown in sexually diverse
form. Recent advances in physiology and surgical technology now enable physicians to
catch most intersexuals at the moment of birth.
Almost at once such infants are entered into a program of hormonal and surgical
management so that they can slip quietly into society as "normal" heterosexual males or
females. I emphasize that the motive is in no way conspiratorial. The aims of the policy
are genuinely humanitarian, reflecting the wish that people be able to "fit in" both
physically and psychologically In the medical community, however, the assumptions
behind that wish-- that there be only two sexes, that heterosexuality alone is normal, that
there is one true model of psychological health-- have gone virtually unexamined.
The word hermaphrodite comes from the Greek name Hermes, variously known as the
messenger of the gods, the patron of music, the controller of dreams or the protector of
livestock, and Aphrodite, the goddess of sexual love and beauty. According to Greek
mythology, those two gods parented Hermaphroditus, who at age fifteen became half
male and half female when his body fused with the body of a nymph he fell in love with.
In some true hermaphrodites the testis and the ovary grow separately but bilaterally, in
others they grow together within the same organ, forming an ovo-testis. Not infrequently,
at least one of the gonads functions quite well, producing either sperm cells or eggs, as
well as functional levels of the sex hormones-- androgens or estrogens. Although in
theory it might be possible for a true hermaphrodite to become both father and mother to
a child, in practice the appropriate ducts and tubes are not configured so that egg and
sperm can meet.
In contrast with the true hermaphrodites, the pseudohermaphrodites possess two gonads
of the same kind along with the
usual male (XY) or female (XX) chromosomal makeup. But their external genitalia and
secondary sex characteristics do not match their chromosomes. Thus merms have testes
and XY chromosomes, yet they also have a vagina and a clitoris, and at puberty they often
develop breasts. They do not menstruate, however. Ferms have ovaries, two X
chromosomes and sometimes a uterus, but they also have at least partly masculine
external genitalia. Without medical intervention they can develop beards, deep voices and
adult-size penises.
No classification scheme could more than suggest the variety of sexual anatomy
encountered in clinical practice. In 1969, for example, two French investigators, Paul
Guinet of the Endocrine Clinic in Lyons and Jacques Decourt of the Endocrine Clinic in
Paris, described ninety-eight cases of true hermaphroditism-- again, signifying people
with both ovarian and testicular tissue-- solely according to the appearance of the
external genitalia and the accompanying ducts. In some cases the people exhibited
strongly feminine development. They had separate openings for the vagina and the
urethra, a cleft vulva defined by both the large and the small labia, or vaginal lips, and at
puberty they developed breasts and usually began to menstruate. It was the oversize and
sexually alert clitoris, which threatened sometimes at puberty to grow into a penis, that
usually impelled them to seek medical attention. Members of another group also had
breasts and a feminine body type, and they menstruated. But their labia were at least
partly fused, forming an incomplete scrotum. The phallus (here an embryological term for
a structure that during usual development goes on to form either a clitoris or a penis) was
between 1.5 and 2.8 inches long; nevertheless, they urinated through a urethra that opened
into or near the vagina.
By far the most frequent form of true hermaphrodite encountered by Guinet and
Decourt-- 55 percent-- appeared to have a more masculine physique. In such people the
urethra runs either through or near the phallus, which looks more like a penis than a
clitoris. Any menstrual blood exits periodically during urination. But in spite of the
relatively male appearance of the genitalia, breasts appear at puberty. It is possible that a
sample larger than ninety-eight so-called true hermaphrodites would yield even more
contrasts and subtleties. Suffice it to say that the varieties are so diverse that it is possible
to know which parts are present and what is attached to what only after exploratory
surgery.
The embryological origins of human hermaphrodites clearly fit what is known about male
and female sexual development. The embryonic gonad generally chooses early in
development to follow either a male or a female sexual pathway; for the ovo-testis,
however, that choice is fudged. Similarly, the embryonic phallus most often ends up as a
clitoris or a penis, but the existence of intermediate states comes as no surprise to the
embryologist. There are also uro-genital swellings in the embryo that usually either stay
open and become the vaginal labia or fuse and become a scrotum. In some
hermaphrodites, though, the choice of opening or closing is ambivalent. Finally, all
mammalian embryos have structures that can become the female uterus and the fallopian
tubes, as well as structures that can become part of the male sperm-transport system.
Typically either the male or the female set of those primordial genital organs degenerates,
and the remaining structures achieve their sex-appropriate future. In hermaphrodites both
sets of organs develop to varying degrees.
Intersexuality itself is old news. Hermaphrodites, for instance, are often featured in stories
about human origins. Early biblical scholars believed Adam began life as a hermaphrodite
and later divided into two people-- a male and a female-- after falling from grace.
According to Plato there once were three sexes-- male, female and hermaphrodite-- but
the third sex was lost with time.
Both the Talmud and the Tosefta, the Jewish books of law, list extensive regulations for
people of mixed sex. The Tosefta expressly forbids hermaphrodites to inherit their
fathers' estates (like daughters), to seclude themselves with women (like sons) or to shave
(like men). When hermaphrodites menstruate they must be isolated from men (like
women); they are disqualified from serving as witnesses or as priests (like women), but
the laws of pederasty apply to them.
In Europe a pattern emerged by the end of the Middle Ages that, in a sense, has lasted to
the present day: hermaphrodites were compelled to choose an established gender role and
stick with it. The penalty for transgression was often death. Thus in the 1600s a Scottish
hermaphrodite living as a woman was buried alive after impregnating his/her master's
daughter.
For questions of inheritance, legitimacy, paternity, succession to title and eligibility for
certain professions to be determined, modern Anglo-Saxon legal systems require that
newborns be registered as either male or female. In the U.S. today sex determination is
governed by state laws. Illinois permits adults to change the sex recorded on their birth
certificates should a physician attest to having performed the appropriate surgery The
New York Academy of Medicine on the other hand, has taken an opposite view. In spite
of surgical alterations of the external genitalia, the academy argued in 1966, the
chromosomal sex remains the same. By that measure, a person's wish to conceal his or
her original sex cannot outweigh the public interest in protection against fraud.
During this century the medical community has completed what the legal world began--
the complete erasure of any form of embodied sex that does not conform to a malefemale,
heterosexual pattern. Ironically, a more sophisticated knowledge of the
complexity of sexual systems has led to the repression of such intricacy.
In 1937 the urologist Hugh H. Young of Johns Hopkins University published a volume
titled Genital Abnormalities, Hermaphrodites and Related Adrenal Diseases. The book is
remarkable for its erudition, scientific insight and open-mindedness. In it Young drew
together a wealth of carefully documented case histories to demonstrate and study the
medical treatment of such "accidents of birth." Young did not pass judgment on the
people he studied, nor did he attempt to coerce into treatment those intersexuals; who
rejected that option. And he showed unusual evenhandedness in referring to those people
who had sexual experiences as both men and women as "Practicing hermaphrodites."
One of Young's more interesting cases was a hermaphrodite named Emma who had
grown up as a female. Emma had both a penis-size clitoris and a vagina, which made it
possible for him/ her to have "normal" heterosexual sex with both men and women. As a
teenager Emma had had sex with a number of girls to whom s/he was deeply attracted;
but at the age of nineteen s/he had married a man. Unfortunately, he had given Emma
little sexual pleasure (though he had had no complaints), and so throughout that marriage
and subsequent ones Emma had kept girlfriends on the side. With some frequency s/he
had pleasurable sex with them. Young describes his subject as appearing "to be quite
content and even happy." In conversation Emma occasionally told him of his/her wish to
be a man, a circumstance Young said would be relatively easy to bring about. But
Emma's reply strikes a heroic blow for self-interest:
Would you have to remove that vagina? I don't know about that because that's my meal
ticket. If you did that, I would have to quit my husband and go to work, so I think I'll keep
it and stay as I am. My husband supports me well,
and even though I don't have any sexual pleasure with him, I do have lots with my
girlfriends.
Yet even as Young was illuminating intersexuality with the light of scientific reason, he
was beginning its suppression. For his book is also an extended treatise on the most
modem surgical and hormonal methods of changing intersexuals, into either males or
females. Young may have differed from his successors in being less judgmental and
controlling of the patients and their families, but he nonetheless supplied the foundation
on which current intervention practices were built.
By 1969, when the English physicians Christopher J. Dewhurst and Ronald R. Gordon
wrote The Intersexual Disorders, medical and surgical approaches to intersexuality had
neared a state of rigid uniformity. It is hardly surprising that such a hardening of opinion
took place in the era of the feminine mystique-- of the post-Second World War flight to
the suburbs and the strict division of family roles according to sex. That the medical
consensus was not quite universal (or perhaps that it seemed poised to break apart again)
can be gleaned from the near-hysterical tone of Dewhurst and Gordon's book, which
contrasts markedly with the calm reason of Young's founding work. Consider their
opening description of an intersexual newborn:
One can only attempt to imagine the anguish of the parents. That a newborn should have
a deformity ... [affecting] so fundamental an issue as the very sex of the child ... is a tragic
event which immediately conjures up visions of a hopeless psychological misfit doomed
to live always as a sexual freak in loneliness and frustration.
Dewhurst and Gordon warned that such a miserable fate would, indeed, be a baby's lot
should the case be improperly managed; "but fortunately," they wrote, "with correct
management the outlook is infinitely better than the poor parents-- emotionally
stunnedby the event-- or indeed anyone without special knowledge could ever imagine."
Scientific dogma has held fast to the assumption that without medical care
hermaphrodites are doomed to a life of misery. Yet there are few empirical studies to
back up that assumption, and some of the same research gathered to build a case for
medical treatment contradicts it. Francies Benton, another of Young's practicing
hermaphrodites, "had not worried over his condition, did not wish to be changed, and was
enjoying life." The same could be said of Emma, the opportunistic hausfrau. Even
Dewhurst and Gordon, adamant about the psychological importance of treating
intersexuals; at the infant stage, acknowledged great success in "changing the sex" of
older patients. They reported on twenty cases of children reclassified into a different sex
after the supposedly critical age of eighteen months. They asserted that all the
reclassifications were "successful," and they wondered then whether reregistration could
be "recommended more readily than [had] been suggested so far."
The treatment of intersexuality in this century provides a dear example of what the French
historian Michel Foucault has called biopower. The knowledge developed in
biochemistry, embryology, endocrinology, psychology and surgery has enabled physicians
to control the very sex of the human body. The multiple contradictions in that kind of
power call for some scrutiny. On the one hand, the medical "management" of
intersexuality certainly developed as part of an attempt to free people from perceived
psychological pain (though whether the pain was the patient's, the parents' or the
physician's is unclear). And if one accepts the assumption that in a sex-divided culture
people can realize their greatest potential for happiness and productivity only if they are
sure they belong to one of only two acknowledged sexes, modern medicine has been
extremely successful.
On the other hand, the same medical accomplishments can be read not as progress but as
a mode of discipline. Hermaphrodites have unruly bodies. They do not fall naturally into
a binary classification; only a surgical shoehorn can put them there. But why should we
care if a "woman," defined as one who has breasts, a vagina, a uterus and ovaries and who
menstruates, also has a clitoris large enough to penetrate the vagina of another woman?
Why should we care if there are people whose biological equipment enables them to have
sex "naturally" with both men and women? The answers seem to lie in a cultural need to
maintain clear distinctions between the sexes. Society mandates the control of intersexual
bodies because they blur and bridge the great divide. Inasmuch as hermaphrodites literally
embody both sexes, they challenge traditional beliefs about sexual difference: they
possess the irritating ability to live sometimes as one sex and sometimes the other, and
they raise the specter of homosexuality.
But what if things were altogether different? Imagine a world in which the same
knowledge that has enabled medicine to intervene in the management of intersexual
patients has been placed at the service of multiple sexualities. Imagine that the sexes have
multiplied beyond currently imaginable limits. It would have to be a world of shared
powers. Patient and physician, parent and child, male and female, heterosexual and
homosexual-- all those oppositions and others would have to be dissolved as sources of
division. A new ethic of medical treatment would arise, one that would permit ambiguity
in a culture that had overcome sexual division. The central mission of medical treatment
would be to preserve life. Thus hermaphrodites would be concerned primarily not about
whether they can conform to society but about whether they might develop potentially
life-threatening conditions-- hernias, gonadal tumors, salt imbalance caused by adrenal
malfunction-- that sometimes accompany hermaphroditic development. In my ideal
world medical intervention for intersexuals would take place only rarely before the age of
reason; subsequent treatment would be a cooperative venture between physician, patient
and other advisers trained in issues of gender multiplicity.
I do not pretend that the transition to my utopia would be smooth. Sex, even the
supposedly "normal," heterosexual kind, continues to cause untold anxieties in Western
society. And certainly a culture that has yet to come to grips-- religiously and, in some
states, legally-- with the ancient and relatively uncomplicated reality of homosexual love
will not readily embrace intersexuality. No doubt the most troublesome arena by far
would be the rearing of children. Parents, at least since the Victorian era, have fretted,
sometimes to the point of outright denial, over the fact that their children are sexual
beings.
All that and more amply explains why intersexual children are generally squeezed into
one of the two prevailing sexual categories. But what would be the psychological
consequences of taking the alternative road-- raising children as unabashed intersexuals?
On the surface that tack seems fraught with peril. What, for example, would happen to the
intersexual child amid the unrelenting cruelty of the school yard? When the time came to
shower in gym class, what horrors and humiliations would await the intersexual as his/her
anatomy was displayed in all its nontraditional glory? In whose gym class would s/he
register to begin with? What bathroom would s/he use? And how on earth would Mom
and Dad help shepherd him/her through the mine field of puberty?
In the past thirty years those questions have been ignored, as the scientific community
has, with remarkable unanimity, avoided contemplating the alternative route of
unimpeded intersexuality, But modem investigators tend to overlook a substantial body of
case histories, most of them compiled between 1930 and 1960, before surgical
intervention became rampant. Almost without exception, those reports describe children
who grew up knowing they were intersexual (though they did not advertise it) and
adjusted to their unusual status. Some of the studies are richly detailed-- described at the
level of gym-class showering (which most intersexuals avoided without incident); in any
event, there is not a psychotic or a suicide in the lot.
Still, the nuances of socialization among intersexuals cry out for more sophisticated
analysis. Clearly, before my vision of sexual multiplicity can be realized, the first openly
intersexual children and their parents will have to be brave pioneers who will bear the
brunt of society's growing pains. But in the long view -- though it could take generations
to achieve -- the prize might be a society in which sexuality is something to be
celebrated for its subtletites; and not something to be feared or ridiculed.
THE FIVE SEXES, REVISITED
The emerging recognition that people come in bewildering sexual varieties is testing
medical values and social norms
As Cheryl Chase stepped to the front of the packed meeting room in the Sheraton Boston
Hotel, nervous coughs made the tension audible. Chase, an activist for intersexual rights,
had been invited to address the May 2000 meeting of the Lawson Wilkins Pediatric
Endocrine Society (LWPES), the largest organization in the United States for specialists
in children's hormones. Her talk would be the grand finale to a four-hour symposium on
the treatment of genital ambiguity in newborns, infants born with a mixture of both male
and female anatomy, or genitals that appear to differ from their chromosomal sex. The
topic was hardly a novel one to the assembled physicians.
Yet Chase's appearance before the group was remarkable. Three and a half years earlier,
the American Academy of Pediatrics had refused her request for a chance to present the
patients' viewpoint on the treatment of genital ambiguity, dismissing Chase and her
supporters as "zealots." About two dozen intersex people had responded by throwing up a
picket line. The Intersex Society of North America (ISNA) even issued a press release:
"Hermaphrodites Target Kiddie Docs."
It had done my 1960s street-activist heart good. In the short run, I said to Chase at the
time, the picketing would make people angry. But eventually, I assured her, the doors
then closed would open. Now, as Chase began to address the physicians at their own
convention, that prediction was coming true. Her talk, titled "Sexual Ambiguity: The
Patient-Centered Approach," was a measured critique of the near-universal practice of
performing immediate, "corrective" surgery on thousands of infants born each year with
ambiguous genitalia. Chase herself lives with the consequences of such surgery. Yet her
audience, the very endocrinologists and surgeons Chase was accusing of reacting with
"surgery and shame," received her with respect. Even more remarkably, many of the
speakers who preceded her at the session had already spoken of the need to scrap current
practices in favor of treatments more centered on psychological counseling.
What led to such a dramatic reversal of fortune? Certainly, Chase's talk at the LWPES
symposium was a vindication of her persistence in seeking attention for her cause. But
her invitation to speak was also a watershed in the evolving discussion about how to treat
children with ambiguous genitalia. And that discussion, in turn, is the tip of a biocultural
iceberg--the gender iceberg--that continues to rock both medicine and our culture at large.
Chase made her first national appearance in 1993, in these very pages, announcing the
formation of ISNA in a letter responding to an essay I had written for The Sciences, titled
"The Five Sexes" [March/April 1993]. In that article I argued that the two-sex system
embedded in our society is not adequate to encompass the full spectrum of human
sexuality. In its place, I suggested a five-sex system. In addition to males and females, I
included "herms" (named after true hermaphrodites, people born with both a testis and an
ovary); "merms" (male pseudohermaphrodites, who are born with testes and some aspect
of female genitalia); and "ferms" (female pseudohermaphrodites, who have ovaries
combined with some aspect of male genitalia).
I had intended to be provocative, but I had also written with tongue firmly in cheek. So I
was surprised by the extent of the controversy the article unleashed. Right-wing
Christians were outraged, and connected my idea of five sexes with the United Nations--
sponsored Fourth World Conference on Women, held in Beijing in September 1995. At
the same time, the article delighted others who felt constrained by the current sex and
gender system.
Clearly, I had struck a nerve. The fact that so many people could get riled up by my
proposal to revamp our sex and gender system suggested that change--as well as
resistance to it--might be in the offing. Indeed, a lot has changed since 1993, and I like to
think that my article was an important stimulus. As if from nowhere, intersexuals are
materializing before our very eyes. Like Chase, many have become political organizers,
who lobby physicians and politicians to change current treatment practices. But more
generally, though perhaps no less provocatively, the boundaries separating masculine and
feminine seem harder than ever to define.
Some find the changes under way deeply disturbing. Others find them liberating.
Who is an intersexual--and how many intersexuals are there? The concept of
intersexuality is rooted in the very ideas of male and female. In the idealized, Platonic,
biological world, human beings are divided into two kinds: a perfectly dimorphic species.
Males have an X and a Y chromosome, testes, a penis and all of the appropriate internal
plumbing for delivering urine and semen to the outside world. They also have wellknown
secondary sexual characteristics, including a muscular build and facial hair.
Women have two X chromosomes, ovaries, all of the internal plumbing to transport urine
and ova to the outside world, a system to support pregnancy and fetal development, as
well as a variety of recognizable secondary sexual characteristics.
That idealized story papers over many obvious caveats: some women have facial hair,
some men have none; some women speak with deep voices, some men veritably squeak.
Less well known is the fact that, on close inspection, absolute dimorphism disintegrates
even at the level of basic biology. Chromosomes, hormones, the internal sex structures,
the gonads and the external genitalia all vary more than most people realize. Those born
outside of the Platonic dimorphic mold are called intersexuals.
In "The Five Sexes" I reported an estimate by a psychologist expert in the treatment of
intersexuals, suggesting that some 4 percent of all live births are intersexual. Then,
together with a group of Brown University undergraduates, I set out to conduct the first
systematic assessment of the available data on intersexual birthrates. We scoured the
medical literature for estimates of the frequency of various categories of intersexuality,
from additional chromosomes to mixed gonads, hormones and genitalia. For some
conditions we could find only anecdotal evidence; for most, however, numbers exist. On
the basis of that evidence, we calculated that for every 1,000 children born, seventeen are
intersexual in some form. That number--1.7 percent--is a ballpark estimate, not a precise
count, though we believe it is more accurate than the 4 percent I reported.
Our figure represents all chromosomal, anatomical and hormonal exceptions to the
dimorphic ideal; the number of intersexuals who might, potentially, be subject to surgery
as infants is smaller--probably between one in 1,000 and one in 2,000 live births.
Furthermore, because some populations possess the relevant genes at high frequency, the
intersexual birthrate is not uniform throughout the world.
Consider, for instance, the gene for congenital adrenal hyperplasia (CAH). When the
CAH gene is inherited from both parents, it leads to a baby with masculinized external
genitalia who possesses two X chromosomes and the internal reproductive organs of a
potentially fertile woman. The frequency of the gene varies widely around the world: in
New Zealand it occurs in only forty-three children per million; among the Yupik Eskimo
of southwestern Alaska, its frequency is 3,500 per million.
Intersexuality has always been to some extent a matter of definition. And in the past
century physicians have been the ones who defined children as intersexual--and provided
the remedies. When only the chromosomes are unusual, but the external genitalia and
gonads clearly indicate either a male or a female, physicians do not advocate intervention.
Indeed, it is not clear what kind of intervention could be advocated in such cases. But the
story is quite different when infants are born with mixed genitalia, or with external
genitals that seem at odds with the baby's gonads. Most clinics now specializing in the
treatment of intersex babies rely on case-management principles developed in the 1950s
by the psychologist John Money and the psychiatrists Joan G. Hampson and John L.
Hampson, all of Johns Hopkins University in Baltimore, Maryland. Money believed that
gender identity is completely malleable for about eighteen months after birth. Thus, he
argued, when a treatment team is presented with an infant who has ambiguous genitalia,
the team could make a gender assignment solely on the basis of what made the best
surgical sense. The physicians could then simply encourage the parents to raise the child
according to the surgically assigned gender. Following that course, most physicians
maintained, would eliminate psychological distress for both the patient and the parents.
Indeed, treatment teams were never to use such words as "intersex" or "hermaphrodite";
instead, they were to tell parents that nature intended the baby to be the boy or the girl
that the physicians had determined it was. Through surgery, the physicians were merely
completing nature's intention.
Although Money and the Hampsons published detailed case studies of intersex children
who they said had adjusted well to their gender assignments, Money thought one case in
particular proved his theory. It was a dramatic example, inasmuch as it did not involve
intersexuality at all: one of a pair of identical twin boys lost his penis as a result of a
circumcision accident. Money recommended that "John" (as he came to be known in a
later case study) be surgically turned into "Joan" and raised as a girl. In time, Joan grew to
love wearing dresses and having her hair done. Money proudly proclaimed the sex
reassignment a success.
But as recently chronicled by John Colapinto, in his book As Nature Made Him, Joan--
now known to be an adult male named David Reimer--eventually rejected his female
assignment. Even without a functioning penis and testes (which had been removed as part
of the reassignment) John/Joan sought masculinizing medication, and married a woman
with children (whom he adopted).
Since the full conclusion to the John/Joan story came to light, other individuals who were
reassigned as males or females shortly after birth but who later rejected their early
assignments have come forward. So, too, have cases in which the reassignment has
worked--at least into the subject's mid-twenties. But even then the aftermath of the
surgery can be problematic. Genital surgery often leaves scars that reduce sexual
sensitivity. Chase herself had a complete clitoridectomy, a procedure that is less
frequently performed on intersexuals today. But the newer surgeries, which reduce the
size of the clitoral shaft, still greatly reduce sensitivity.
The revelation of cases of failed Reassign-merits and the emergence of intersex activism
have led an increasing number of pediatric endocrinologists, urologists and psychologists
to reexamine the wisdom of early genital surgery. For example, in a talk that preceded
Chase's at the LWPES meeting, the medical ethicist Laurence B. McCullough of the
Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston,
Texas, introduced an ethical framework for the treatment of children with ambiguous
genitalia. Because sex phenotype (the manifestation of genetically and embryologically
determined sexual characteristics) and gender presentation (the sex role projected by the
individual in society) are highly variable, McCullough argues, the various forms of
intersexuality should be defined as normal. All of them fall within the statistically
expected variability of sex and gender. Furthermore, though certain disease states may
accompany some forms of intersexuality, and may require medical intervention,
intersexual conditions are not themselves diseases.
McCullough also contends that in the process of assigning gender, physicians should
minimize what he calls irreversible assignments: taking steps such as the surgical removal
or modification of gonads or genitalia that the patient may one day want to have reversed.
Finally, McCullough urges physicians to abandon their practice of treating the birth of a
child with genital ambiguity as a medical or social emergency. Instead, they should take
the time to perform a thorough medical workup and should disclose everything to the
parents, including the uncertainties about the final outcome. The treatment mantra, in
other words, should be therapy, not surgery.
I believe a new treatment protocol for intersex infants, similar to the one outlined by
McCullough, is close at hand. Treatment should combine some basic medical and ethical
principles with a practical but less drastic approach to the birth of a mixed-sex child. As a
first step, surgery on infants should be performed only to save the child's life or to
substantially improve the child's physical well-being. Physicians may assign a sex--male
or female--to an intersex infant on the basis of the probability that the child's particular
condition will lead to the formation of a particular gender identity. At the same time,
though, practitioners ought to be humble enough to recognize that as the child grows, he
or she may reject the assignment--and they should be wise enough to listen to what the
child has to say. Most important, parents should have access to the full range of
information and options available to them.
Sex assignments made shortly after birth are only the beginning of a long journey.
Consider, for instance, the life of Max Beck: Born intersexual, Max was surgically
assigned as a female and consistently raised as such. Had her medical team followed her
into her early twenties, they would have deemed her assignment a success because she
was married to a man. (It should be noted that success in gender assignment has
traditionally been defined as living in that gender as a heterosexual.) Within a few years,
however, Beck had come out as a butch lesbian; now in her mid-thirties, Beck has
become a man and married his lesbian partner, who (through the miracles of modern
reproductive technology) recently gave birth to a girl.
Transsexuals, people who have an emotional gender at odds with their physical sex, once
described themselves in terms of dimorphic absolutes--males trapped in female bodies, or
vice versa. As such, they sought psychological relief through surgery. Although many still
do, some so-called transgendered people today are content to inhabit a more ambiguous
zone. A male-to-female transsexual, for instance, may come out as a lesbian. Jane, born a
physiological male, is now in her late thirties and living with her wife, whom she married
when her name was still John. Jane takes hormones to feminize herself, but they have not
yet interfered with her ability to engage in intercourse as a man. In her mind Jane has a
lesbian relationship with her wife, though she views their intimate moments as a cross
between lesbian and heterosexual sex.
It might seem natural to regard intersexuals and transgendered people as living midway
between the poles of male and female. But male and female, masculine and feminine,
cannot be parsed as some kind of continuum. Rather, sex and gender are best
conceptualized as points in a multidimensional space. For some time, experts on gender
development have distinguished between sex at the genetic level and at the cellular level
(sex-specific gene expression, X and Y chromosomes); at the hormonal level (in the
fetus, during childhood and after puberty); and at the anatomical level (genitals and
secondary sexual characteristics). Gender identity presumably emerges from all of those
corporeal aspects via some poorly understood interaction with environment and
experience. What has become increasingly clear is that one can find levels of masculinity
and femininity in almost every possible permutation. A chromosomal, hormonal and
genital male (or female) may emerge with a female (or male) gender identity. Or a
chromosomal female with male fetal hormones and masculinized genitalia--but with
female pubertal hormones--may develop a female gender identity.
The Medical and Scientific Communities have yet to adopt a language that is capable of
describing such diversity. In her book Hermaphrodites and the Medical Invention of Sex,
the historian and medical ethicist Alice Domurat Dreger of Michigan State University in
East Lansing documents the emergence of current medical systems for classifying gender
ambiguity. The current usage remains rooted in the Victorian approach to sex. The logical
structure of the commonly used terms "true hermaphrodite," "male pseudohermaphrodite"
and "female pseudohermaphrodite" indicates that only the so-called true hermaphrodite is
a genuine mix of male and female. The others, no matter how confusing their body parts,
are really hidden males or females. Because true hermaphrodites are rare--possibly only
one in 100,000--such a classification system supports the idea that human beings are an
absolutely dimorphic species.
At the dawn of the twenty-first century, when the variability of gender seems so visible,
such a position is hard to maintain. And here, too, the old medical consensus has begun to
crumble. Last fall the pediatric urologist Ian A. Aaronson of the Medical University of
South Carolina in Charleston organized the North American Task Force on Intersexuality
(NATFI) to review the clinical responses to genital ambiguity in infants. Key medical
associations, such as the American Academy of Pediatrics, have endorsed NATFI.
Specialists in surgery, endocrinology, psychology, ethics, psychiatry, genetics and public
health, as well as intersex patient-advocate groups, have joined its ranks.
One of the goals of NATFI is to establish a new sex nomenclature. One proposal under
consideration replaces the current system with emotionally neutral terminology that
emphasizes developmental processes rather than preconceived gender categories. For
example, Type I intersexes develop out of anomalous virilizing influences; Type II result
from some interruption of virilization; and in Type III intersexes the gonads themselves
may not have developed in the expected fashion.
What is clear that since 1993, modern society has moved beyond five sexes to a
recognition that gender variation is normal and, for some people, an arena for playful
exploration. Discussing my "five sexes" proposal in her book Lessons from the
Intersexed, the psychologist Suzanne J. Kessler of the State University of New York at
Purchase drives this point home with great effect:
The limitation with Fausto-Sterling's proposal is that ... [it] still gives genitals ... primary
signifying status and ignores the fact that in the everyday word gender attributions are
made without access to genital inspection. ... What has primacy in everyday life is the
gender that is performed, regardless of the flesh's configuration under the clothes.
I now agree with Kessler's assessment. It would be better for intersexuals and their
supporters to turn everyone's focus away from genitals. Instead, as she suggests, one
should acknowledge that people come in an even wider assortment of sexual identities
and characteristics than mere genitals can distinguish. Some women may have "large
clitorises or fused labia," whereas some men may have "small penises or misshapen
scrota," as Kessler puts it, "phenotypes with no particular clinical or identity meaning."
As clearheaded as Kessler's program is--and despite the progress made in the 1990s--our
society is still far from that ideal. The intersexual or transgendered person who projects a
social gender--what Kessler calls "cultural genitals"--that conflicts with his or her
physical genitals still may die for the transgression. Hence legal protection for people
whose cultural and physical genitals do not match is needed during the current transition
to a more gender-diverse world. One easy step would be to eliminate the category of
"gender" from official documents, such as driver's licenses and passports. Surely
attributes both more visible (such as height, build and eye color) and less visible
(fingerprints and genetic profiles) would be more expedient.
A more far-ranging agenda is presented in the International Bill of Gender Rights,
adopted in 1995 at the fourth annual International Conference on Transgender Law and
Employment Policy in Houston, Texas. It lists ten "gender rights," including the right to
define one's own gender, the right to change one's physical gender if one so chooses and
the right to marry whomever one wishes. The legal bases for such rights are being
hammered out in the courts as I write and, most recently, through the establishment, in
the state of Vermont, of legal same-sex domestic partnerships.
No one could have foreseen such changes in 1993. And the idea that I played some role,
however small, in reducing the pressure--from the medical community as well as from
society at large--to flatten the diversity of human sexes into two diametrically opposed
camps gives me pleasure.
Sometimes people suggest to me, with not a little horror, that I am arguing for a pastel
world in which androgyny reigns and men and women are boringly the same. In my
vision, however, strong colors coexist with pastels. There are and will continue to be
highly masculine people out there; it's just that some of them are women. And some of
the most feminine people I know happen to be men.
Anne Fausto-Sterling is a professor of biology and women's studies at Brown University.
Portions of this article were adapted from her recent book SEXING THE BODY (Basic
Books, 2000).
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