Two ViewsI was pleased to see Ricki Lewis' article "Reevaluating Sex Reassignment."1 The piece is good as far as it goes, but it fails to do justice to the academic work that has been under way for the past five years, and which has used reasoned analysis to call for a change in the practice of sex reassignment surgery at birth. Such academic work has argued instead for greater gender variation and autonomy for the patients on whom surgery is now imposed. I recommend to the readers of The Scientist three books: one by me titled Sexing the Body: Gender Politics and the Construction of Sexuality (Basic Books, 2000); one by Suzanne J. Kessler titled Lessons from the Intersexed (Routledge, 1998); and one by Alice Dreger titled Hermaphrodites and the Medical Invention of Sex (Harvard, 1998).
Changes in medical practice do not happen overnight, but through the hard work of scholars, physicians, and patient advocates. It is important to acknowledge the breadth and depth of such alliances, because they offer insight into how to change social policy.
Professor of Biology and Women's Studies
Providence, RI 02912
The article describes a study by William Reiner on the development of gender identity in genetic males with pelvic field defects who are raised as females.1 Many of these, Reiner's study shows, develop male gender identity despite castration and female rearing.
The article incorrectly implies that the experience of patient-advocacy groups such as the Intersex Society of
North America (ISNA) provides evidence that nature trumps nurture. In fact, gender identity development is complex, and available data make clear that neither nature nor nurture is fully determining. For instance, Jean Wilson has described siblings with 5-alpha-reductase deficiency (which partially interrupts virilization in a genetic male), raised unequivocally female--neither parents nor doctors were aware of the children's anomaly. The siblings developed discordant gender identities, one male and one female, though genetically identical with respect to the endocrine anomaly and having been reared in very similar circumstances (the same family).2
The article implies that the Intersex Society's opposition to plastic surgery on children with genital anomalies is based only upon gender identity concerns. In fact, only a minority of intersex patients reject the sex of assignment. We would be opposed to these surgeries even if gender identity were not at issue. First, the surgeries are based on the idea that difference is pathological. At the same meeting where Reiner presented his data, ethicist Laurence McCullough reminded clinicians that intersexuality is a variation, not a disease, and is not uniformly disvalued by intersex people.3 Second, genital plastic surgeries damage sexual function, and they fail to produce "normal" genital appearance.4
"First, do no harm," says the Hippocratic oath. It's time to halt medically unnecessary plastic surgery on the genitals of those who do not choose it.
Intersex Society of North America
P.O. Box 3070
Ann Arbor, MI 48106
2. J.D. Wilson, "Gender role change in males with deficiency of 5 alpha-reductase or 17 beta-OH-steroid dehydrogenase," presented at Lawson Wilkins Pediatric Endocrine Society Annual Meeting, San Francisco, April 30, 1999.
3. L. McCullough, "Neonatal management of genital ambiguity: legal and ethical ramifications," presented at Lawson Wilkins Pediatric Endocrine Society Annual Meeting, Boston, May 12, 2000.
4. C. Chase, "Surgical progress not the answer to intersexuality," Journal of Clinical Ethics, 9:385-92, 1998.