"genitals as signifiers": when birth is a "social emergency"

Yesterday I started reading Katrina Karkazis' book Fixing Sex: Intersex, Medical Authority, and Lived Experience (2008).  Based on ethnographic research and review of the existing literature, Fixing Sex traces the twentieth-century medical treatment of individuals whom the medical profession identifies as "intersex." Part one of the book discusses the understanding of, and treatment for, intersex conditions in the past -- with a focus on the late twentieth century -- and Part Two explores the decision-making process for children who are born with what doctors feel are sex and/or gender atypical bodies. Since Karkazis draws heavily on interviews she conducted with the parents of diagnosed children and adults who had been treated for various conditions, I'm excited about getting into this second half of her study, which I have just started this afternoon.

What I really wanted to share with you in this post, though, is several paragraphs from the first chapter of Part Two in which Karkazis describes the way myriad ways in which children born with no immediately apparent sex identity are experienced as a matter of "social urgency" by their parents and the medical community. I realize it's kinda academic and somewhat heavy on the specialized terminology. But I think she's packing some pretty important stuff into these paragraphs (pp. 95-97). Reading this narrative, I just felt an overwhelming sadness in my chest for these tiny persons whose very being is somehow construed as problematic -- who cannot be incorporated into the human community, it seems -- because they lack a clear "girl" or "boy" box in which to be situated.

No sooner than a baby is born its sex is announced by the attending clinician, based on an inspection and understanding of the external genitalia as either male or female. The process of sex identification at birth is one in which genitals are granted the power of synecdochic representation. Genitals, and the sex designation to which they give rise, create gender expectations for almost every aspect of an individual's life. Not only are they usually the sole factor of sex determination but they are also assumed to correspond with fully and uniformly differentiated internal sex organs and are further charged with the task of signifying and predicting gender (whether identity, role, or behavior) and even sexuality. Put another way, if a baby is labeled "female" at birth, it is assumed that that person will grow up to understand herself as a woman, to dress and act like a woman, and to desire and have sex with men. Because this is the usual course of events, it is assumed natural. At birth genitals are thus viewed as symbolically and literally revealing the truth of gender.

At no time are the connections between genitals and gender more evident than when the genitalia of an infant either do not signal or else missignal sex. In these instances, atypical or, in clinical terms, ambiguous genitals are seen not as the representation of sex, but as the signal of a misinterpretation of sex. Without legible genitals, and thus without an evident or stable sex, an infant with "ambiguous" genitals flutters not simply between sexes but between genders and sexualities: such infants are neither readily male nor female, neither masculine nor feminine, and consequently neither readily homosexual nor heterosexual. So-called ambiguity is posited as the ground of sexual and gendered difference: a prediscursive, precultural dimension of bodiliness rather than an effect of a social system that requires a binary and incommensurate set of two sexes.
In other words, the body is seen as problematic and wrong because it fails to match our expected (and culturally-created) binary categories, rather than such a situation causing us to reconsider our categories that fail to take into account the existence of bodies that do not readily fit into them.

Bodies with atypical or conflicting biological markers are troublesome because they disturb the social body; they also disrupt the process of determining an infant's place in the world. Gender-atypical genitals (and bodies) create anxieties about the borders of properly gendered subjects and a desire to reaffirm those borders. In a culture that requires clear gender division -- a culture in which, to paraphrase Michel Foucault, we truly need a true sex -- gender-atypical bodies threaten an entire system of laws, rights, responsibilities, and privileges built on the notions of discrete and binary gender.

As a result, clinicians often rush to stabilize the sex of infants with intersex diagnoses. The urgency of this undertaking, to which parents no doubt contribute, all too often overrides the joy of the birth, as an infant may be whisked away for medical tests before the parents have had any chance to bond with their baby. Parents may be discouraged from naming their baby before a gender assignment is made. To avoid using gendered pronouns, clinical caregivers may refer to the newborn as "the baby." Because the announcement of sex is usually considered a prerequisite to naming a child, which is in turn a prerequisite to filing a legal notice of the birth, there is a sense in which biology determines -- or confuses -- a newborn's entire social and legal identity. Physically alive but denied a sex and a name, the infant has no social existence. Personhood depends on gender assignment.
This might seem like a somewhat silly comparison, but for some reason scenario -- in addition to making me almost physically ill at the thought of newborns being kept from their parents and made to undergo invasive tests -- reminds me of our new kitty, whom we adopted last weekend from a foster home. We know the cat is female from the rescue organization, but we have not yet settled on a name. This hasn't stopped us from lavishing love and attention upon our kitty, showering her with endearments and otherwise trying to let her know in no uncertain terms that she is now part of our family.  While I understand that, in our culture, most names are imbued with gender, terms of endearment ("sweetheart," "love," "darling") are pretty universal -- and with a preverbal infant it's the tone not the words that matter anyway. It's the sound of a familiar voice and the warmth it conveys that matter. The fact that the adults in this scenario seem to have lost sight of this due to being wrapped up in their own cultural anxieties makes me sick to my stomach.
Monica Cole, whose daughter has CAH, describes living with this uncertainty after the birth of her baby: "The doctor said we needed an ultrasound to determine our baby's internal sex organs, and a genetic test, which could take a week. Well, how could we not know the gender of our baby for a week? I had a hard time not being able to say 'he' or 'she' and 'baby' was so distant. The hospital had only blue-striped or pink-striped baby hats, and the nurse asked which we would like to use. I picked a blue hat and decided to use a male pronoun. The nurses followed our lead of what pronoun to use, but they also placed both an 'I'm a boy' and 'I'm a girl' cards on the baby tub."
"How could we not know the gender of our baby for a week?" Cole's question is posed as if the answer is self-evident: it was impossible for her, and the hospital staff that surrounded their family, to allow the child to exist without categorizing it. The trappings of the hospital stay (the birth announcements, the labeling of the baby "tub," the hats -- all of these were predicated on a gender binary; there was no third -- let alone forth, fifth, sixth -- option).

The birth of a baby with an intersex diagnosis is thus considered a social emergency in which medical experts are called on to intervene. The entire process could be understood as what the anthropologist Victor Turner has called a "social drama" with four stages: breach, crisis, redressive action, and reintegration. The breach or schism in the social order caused by the birth of a baby with atypical genitals (and this no obvious gender assignment) produces a crisis that must be addressed because it threatens social norms. The redressive action is the culturally defined process through which gender is assigned. Although not all parties may agree about the correct gender assignment for a particular infant all agree that the resolution of indeterminate sex is necessary [emphasis mine], and thus some accept a particular decision as final simply to bring about closure. Reintegration eliminates the original breach that precipitated the crisis. Treatment decisions remove biological or phenotypic atypicality, recreated a particular gendered world.

As this chapter and the next will reveal, clinicians and parents typically share the same goal, though their opinions on how to attain it may be diametrically opposed: to use the best medical technologies available to adapt the infant to life within the binary gender model; living as much as possible as a "normal" male or female.
It's not that I didn't understand that gender anxiety exists, or that the desire to sort individuals into a binary gender system is extremely compelling in our culture. I am not particularly surprised by this description of events. This does not mean that it fails to distress me. What appalled me about this passage was the degree to which none of the adults in this situation seem capable to stepping back and letting the situation be a non-emergency. In most of these instances, a healthy child has been born. This child is not in pain; this child is not suffering from something that could threaten their existence. There is no need for immediate medical intervention in order for this infant human being to survive. So can't we all celebrate this new life? Can't we welcome this tiny new person into the human family? Does a person really require a gender identity in order to be welcomed and cherished and loved for who they are?

As evidenced by Karkazis' account, it appears that they do. And that, in turn, seems like a pretty sick commentary on the relative importance of human beings vs. categories in our culture.

What I can't help thinking as I read Fixing Sex is what sort of birth experience these children would have if, instead of a general consensus that they must be made to conform these children were simply welcomed? What if, instead of confirming the parents' likely anxieties about the sex atypical nature of their child, clinicians were able to calm parents down and encourage them to get to know their child as an individual rather than as a "he" or a "she"? I can't help thinking that this would be a phenomenal place of strength out of which a child would have the best possible opportunity to thrive and become themselves in the world, rather than being taught -- physically, emotionally, and socially -- from the first moments of birth that conformity is a priority, regardless of the cost.


  1. I know this is so very not the point, but ... yay you adopted a cat! Congratulations!

  2. @anna *blush* -- thanks for reading it!

    @Molly -- *giggle* thanks for the congrats :) We just adopted our kitty this weekend and she steadfastly refuses to settle on a name. but we love her anyway -- pictures to come at some point soon.

  3. Thank you for writing about this book, it is on my wish list. I see that it will be emotionally very difficult to get through, as I second your last paragraph very strongly.

    I think this is my first comment here, but I've been following your blog for a few weeks now and think it's great :)

  4. @Emily Jane

    Thanks for stopping by (and de-lurking to comment!) ... always fun to know there are other people out there who are interested in the same ideas I am :).


  5. Thank you for drawing attention to this book, and for your own thoughts. I would just add that, although I agree with everything you say, there is another set of circumstances which is equally, and differently challenging. That is when the inter sex situation (trying to avoid the word condition) is identified later in life, for example at the start of an atypical puberty. Again "remedial" steps may be taken, but in this case the child is intellectually and emotionally part of the situation, often agonisingly so.