The Boston Batwanger Hermaphrodite

[Virgen Vanier]

In the 1950s, a team of medical specialists at Johns Hopkins University developed what has come to be called the "optimum gender of rearing" system for treating children with intersex. The notion was that the main thing you had to do in cases of intersex was to get the gender assignment settled early, so kids would grow up to be good (believable and straight) girls and boys. Under the theoretic leadership of psychologist John Money, the Hopkins team believed that gender was all about nurture--that you could make any child into a "real" girl or boy if you made their bodies look right early (before about 18 months of age), and made them and their parents believe the gender assignment. Though the Hopkins team wrote early on that children should be told the truth about their intersex histories in age-appropriate ways, in practice many medical care providers lied to patients or actively withheld medical history information from them.[1] Medical textbooks frequently gave doctors advice about how to lie to patients with intersex.[2] As the "Hopkins model spread":/articles/daaboul_history throughout the developed world, surgeons performed cosmetic genital surgeries on intersex children without their consent, believing this was necessary and efficacious. Endocrinologists, meanwhile, manipulated patients' hormones to try to get the bodies of patients to do what they thought was necessary not just for physical health, but for psycho-social health (i.e., getting the body to look sexually "normal"). So what was wrong with this model? To start with, lying to patients is not only unethical, it is bad medicine. Patients who were lied to figured that much out, and often stopped getting medical care they needed to stay healthy. (For example, some stopped taking hormone replacement therapy--critical after gonadectomy--and wound up with life-threatening osteoporosis at an early age.) They also suffered psychological harm from these practices, because they got the message that they were so freakish even their doctors could not speak the truth of their bodies to them. (A lot of doctors still have not told their present and former patients the name of their conditions. Some still withhold medical records from patients and from parents/guardians of minor children.) Second, the system was and is literally sexist: that is, it treats children thought to be girls differently than children thought to be boys. In this approach (still going on at Hopkins so far as we can tell), doctors' primary concern for children thought to be girls is preservation of fertility (not sexual sensation), and for children thought to be boys, size and function of the phallus. Third, the "standards" used for genital anatomy have been arbitrary and illogical. For example, under the "optimum gender of rearing" model, boys born with penises doctors considered small were made into girls--even though other doctors believed (and showed[3]) they could be raised as boys without castration, genital surgery, and hormone replacement. Girls with clitorises their doctors think are "too big" still find themselves in operating theatres with surgeons cutting away at their healthy genital tissue.[4] Paradoxically, though all medical experts agree the identification of intersex anatomy at birth is primarily a psycho-social (not medical) concern, it is still treated almost exclusively with surgery. Parental distress is treated with the child being sent off to surgery. This is not an appropriate form of care for parents or children.[5] There is no evidence that children who grow up with intersex genitals are worse off psychologically than those who are altered. In fact, there is evidence that children who grow up with intersex genitals do well psychologically. In other words, these surgeries happen before the age of assent or consent without real cause. "Ambiguous" genitalia are not diseased, nor do they cause disease; they just look funny to some people. There is substantial evidence that people who have been treated under the "optimum gender of rearing" model have suffered harm, psychological and physical. This does not mean doctors intended to harm their patients; far from it. But good intentions are inadequate reasons to maintain a practice that has shown to be unethical and unscientific. Finally, parents consenting to intersex surgeries do not appear to be fully informed about the available evidence, about alternatives available to them, about the risks associated with surgeries, or about the theoretical problems underlying the "optimum gender of rearing" approach. For example, they are typically not told the evidence that gender identity may emerge to an important degree from prenatal hormonal actions on the brain--and thus, that you can't "make" a child a maintain a particular gender identity in the long term by doing surgery on him or her in infancy.[6] To read more about the problems with the traditional treatment of intersex, see Alice Dreger's "'Ambiguous Sex'--or Ambivalent Medicine":/articles/ambivalent_medicine, The Hastings Center Report, May/June 1998, vol. 28, issue 3, pp. 24-35. To read more about how the concealment model differs from ISNA's recommended patient-centered model, take a look at our chart called "Shifting the Paradigm of Intersex Treatment":/compare. To read more about the history of intersex treatment and the intersex rights movement, go to our FAQ called "What's the history behind the intersex rights movement?":/faq/history and check out the autobiographical article by "Dr. Jorge Daaboul":/articles/daaboul_history. fn1. For examples of people who were lied to and deceived, check out "Hermaphrodites Speak":/videos/hermaphrodites_speak and "Chrysalis":/books/chrysalis. fn2. For documentation, see Alice Domurat Dreger, "Ambiguous Sex--or Ambivalent Medicine? Ethical Issues in the Treatment of Intersexuality":/articles/ambivalent_medicine. Hastings Center Report, 28, 3 (May/June 1998): 24-35. fn3. For evidence boys with small penises do well without sex re-assignment, see Justine M. Reilly and C. R. J. Woodhouse, "Small Penis and the Male Sexual Role," Journal of Urology, 142 (1989): 569-571, and see the autobiography of Hale Hawbecker in "Intersex in the Age of Ethics":/books/ageofethics. fn4. See what UCSF's Laurence Baskin and Indiana's Richard Rink had to say at the "American Academy of Pediatrics Urology Section's 2004 annual meeting":/node/655. fn5. See Edmund G. Howe, "Intersexuality: What Should Care Providers Do Now," Journal of Clinical Ethics, 9, 4 (Winter 1998): 337-344, reprinted in "Intersex in the Age of Ethics":/books/ageofethics. fn6. On this point, see William G. Reiner and John P. Gearhart, "Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth," New England Journal of Medicine, 350, 4 (Jan. 22, 2004): 333-341, "summarized and reviewed by Vernon Rosario":/node/564; see also our FAQ "Who was David Reimer?":/faq/reimer; and see "Pediatric Assignment of Sex: A Critical Reappraisal":/books/reappraisal.



The Boston Batwanger Hermaphrodite

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No. The mythological term "hermaphrodite" implies that a person is both fully male and fully female. This is a physiologic impossibility. The words "hermaphrodite" and "pseudo-hermaphrodite" are stigmatizing and misleading words. Unfortunately, some medical personnel still use them to refer to people with certain intersex conditions, because they still subscribe to an outdated nomenclature that uses gonadal anatomy as the basis of sex classification. In a paper titled "Changing the Nomenclature/Taxonomy for Intersex: A Scientific and Clinical Rationale":/node/979, five ISNA-associated experts recommend that all terms based on the root "hermaphrodite" be abandoned because they are scientifically specious and clinically problematic. The terms fail to reflect modern scientific understandings of intersex conditions, confuse clinicians, harm patients, and panic parents. We think it is much better for everyone involved when specific condition names are used in medical research and practice. To read more about the Victorian origins of the medical terminology of "true" and "pseudo" hermaphroditism, check out chapter 5 of Alice Dreger's "Hermaphrodites and the Medical Invention of Sex":/books/medicalinvention which is available at our "bookshelf":/library/books, or go to our FAQ called "What's the history behind the intersex rights movement?":/faq/history. One more thing: While some intersex people seek to reclaim the word "hermaphrodite" with pride to "reference themselves":/videos/hermaphrodites_speak (much like the words "dyke" and "queer" have been reclaimed by LBGT people), we've learned over the years it is best generally avoided, since the political subtlety is lost on a lot of people.


A lot of people think that doctors do "normalizing" surgeries on infants and children with intersex because, if they didn't, those children would grow up to be very damaged psychologically. In fact, there's virtually no documented evidence for that.[1] Yup, you heard us right: there's virtually no evidence of people with "uncorrected" intersex genitals suffering increased rates of psychological illness or social ostracization. In fact, we do have lots of evidence that people who grow up with "uncorrected" intersex genitals do OK. Here's some of it: A 1937 book, Genital Abnormalities, Hermaphroditism, and Related Adrenal Diseases (Baltimore: Williams and Wilkins) recorded the lives of dozens of adults with "sexual ambiguity," very few of whom were seeking "corrective" surgery. Most were fine with their physical differences. Ironically, the author of that book, Hugh Hampton Young, was a famous surgeon at Johns Hopkins University, the very place that ultimately launched the "optimum gender of rearing" "(concealment-centered)":/faq/concealment model that insisted you had to do "normalizing" surgery on very young children. If the Hopkins team had read Young's work, maybe they would have thought twice about how necessary infant genital surgeries really are. But probably not. Because the very man at Hopkins leading the charge for infant surgeries had himself shown, through extensive research, that people with "uncorrected" intersex have lower rates of psychopathology than the general population. That man was John Money. For his Ph.D. dissertation in psychology at Harvard University in 1952, Money researched hundreds of people with intersex. And yes, he found that they had lower rates of psychopathology than the general population. His theory was that they learned good coping skills. You can read about this in Money's dissertation (never published, but you can order it from Harvard University's Widener Library for about $100) or read the summary of it in John Colapinto's book, "As Nature Made Him":/books/colapinto. In spite of the fact that the Hopkins surgery-based system for treating intersex "spread all over the world":/faq/concealment, some people slipped through, growing up with intersex genitals intact. All the ones we know about did OK. In our video, "Hermaphrodites Speak!":/videos/hermaphrodites_speak, Hida Viloria tells about how she is glad she never had "corrective" surgery. Hida also testified at the "San Francisco Human Rights Commission's open hearing on intersex":/videos/sf_hrc_hearing. Hale Hawbecker--whose parents went against medical advice to sex re-assign him at birth--reports the same in chapter 11 of "Intersex in the Age of Ethics":/books/ageofethics. Also take a look at chapters 7 and 9 in that same book for autobiographies of two women who grew up with large clitorises. As early as 1989, a peer-reviewed study published in the Journal of Urology showed that boys with "micropenis" could do well if raised without surgery and with honesty. Reilly (whose married name is Justine Schober and who is now member of our "Medical Advisory Board":/about/medicalboard) and Woodhouse "interviewed and examined 20 patients with the primary diagnosis of micropenis in infancy" and concluded that "[A] small penis does not preclude normal male role and a micropenis or microphallus alone should not dictate a female gender reassignment in infancy." More particularly, these doctors found that when parents "were well counseled about diagnosis they reflected an attitude of concern but not anxiety about the problem, and they did not convey anxiety to their children. They were honest and explained problems to the child and encouraged normality in behavior. We believe that this is the attitude that allows these children to approach their peers with confidence." (See Justine M. Reilly and C. R. J. Woodhouse, "Small Penis and the Male Sexual Role," Journal of Urology, 142 (1989): 569-571.) This, again, accords with what we know happened to people before the era of enforced infant "normalizing" surgeries. In "Hermaphrodites and the Medical Invention of Sex":/books/medicalinvention, historian Alice Dreger documents many cases of French and British people who, before the age of surgical "correction", fared well socially. Some of them sought advice and information from medical doctors, but very few sought "corrective" surgeries. There has always been sex variation, and there have not been widespread suicides of or assaults on people with variations that could easily be labeled intersex. In his 1949 book, Human Sex Anatomy (Baltimore: The Williams and Wilkins Company), Robert Latou Dickenson demonstrated how adult women and men have widely varied forms of genital anatomy. So, what's the evidence that children with intersex actually need "normalizing" genital surgeries--surgeries that risk their heath, continence, fertility, sensation, and life? We're waiting to see it. fn1. Among doctors, there are lots of rumors that fly around that, if you don't surgically "fix" a child with intersex genitals, she or he will commit suicide, but they're just that: unsubstantiated rumors. Dr. William Reiner talks about that in our video, "The Child with an Intersex Condition: Total Patient Care":/videos/total_patient_care. The only case of suicide by an "uncorrected" person with intersex that we know of was that of Herculine Barbin, but it isn't at all clear why s/he committed suicide; on that point, see Alice Dreger's "Hermaphrodites and the Medical Invention of Sex":/books/medicalinvention, p. 19.

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