Monday, December 04, 2006

N v. N

If anyone's interested, here is my research paper for my Child Development class. I think it's pretty good.

As Nature Made Them?
The Controversy Over Intersexed Individuals
The term “intersex,” as defined in Stedman’s Medical Dictionary and in the Compact Oxford English Dictionary is “one having characteristics of both sexes,” but unfortunately makes no distinction as to what those “characteristics” are (Blizzard, 2002). For the purposes of this analysis, I will go with the most universal and understood application, which is the more specific definition denoting the presence of genital/reproductive structures of both genders, otherwise known as genital ambiguity.
As unique as it might sound, intersexuality affects approximately 1 in 1500 children born in the United States (Lev, 2006). What makes it controversial is that it cuts to the very heart of the decades-old debate over nature versus nurture. Is genitalia, for instance, the only factor that determines a person’s gender? Or is psychosexual identity something that’s learned over time? Do doctors and parents have the right to determine a baby’s gender identity if it is in question, or should the decision-making process be left up to the child, to decide at an older age, when they are capable of making an informed decision about how they want to live?
Back in the 1950’s, the Johns Hopkins research team led by John Money believed that a child’s gender identity could develop as either male or female, regardless of the sex, as long as the gender rearing was in the same direction as the sex assignment (Lev, 2006). But this raises the question of what determines sex assignment in the first place, and how accurately is it applied. Generally, on a newborn infant with ambiguous genitalia, a precise diagnosis is achieved by combining the results of an extensive physical examination and laboratory evaluation. This includes determining the location of the gonads, the “adequacy” of the phallus, and the size and location of a vaginal orifice, if present (Newman, Randolph, and Anderson, 1991). Regardless of the genotype, most children with this condition are believed to be best suited for the female role. The crucial determinant in assigning a male gender is the size of the phallus and whether or not it is “adequate” to support a male sex assignment. Experience has shown that intersexed adults with the most maladjustment in life have been those patients raised as males in the hope that the penis will grow at the pubertal stage to a more “normal” size, but which it ultimately doesn’t. They essentially become men going through life not with a penis so much as a somewhat larger than average clitoris (Newman, Randolph, and Anderson, 1991). Nevertheless, current endocrinology textbooks continue to include phallus size among the important considerations in assigning gender to an ambiguous newborn (Phornphutkul, Fausto-Sterling, and Gruppuso, 1999). All of this continues to beg the question of whether assigning a gender is even the correct thing to do.
Surgically “correcting” ambiguous genitalia based on the sex assignment assessed by pediatric endocrinologists is the current routine and has been the recommended protocol endorsed by the American Pediatric Association for the past 30 years (Lev, 2006). But recent studies have started to show that this may not be the best avenue. The current routine is based on the idea that normalized genitals will lead to normalized psychological and sexual development, but this is far from proven (Lev, 2006). There is very little counseling support for either the parents or the child in these conditions, and deception, lies and secrecy are a typical mode of behavior. Secrecy and silence in a family, however, usually have traumatic effects on children whose memories are often denied, whose questions are typically avoided, and who have been lied to. They suffer from feelings of humiliation and betrayal, especially toward their parents, but also to members of the medical and helping professions, thus preventing them from seeking further help or treatment (Liao, 2003, and Walcutt, 1995, as cited in Lev, 2006).
The standard protocols of determining and assigning a gender, then raising the child as such, are slowly beginning to fall away, largely due to protest by intersexed persons themselves and by longitudinal studies now being performed by the medical community to determine the self-rated quality of life by adult interesexed persons. In 1993, a concerned group of intersexed adults disappointed by their gender assignments as infants by doctors and parents, formed the Intersex Society of North America (ISNA). They have been influential in drawing the attention of the medical community to the fact that the traditional approach to diagnosing and treating intersexed patients needs to be reexamined (Blizzard, 2002). Much focus is now on destigmatization of the conditions and promoting an open and honest dialogue, not only between the parents and the health care professionals, but also between the parents and the child (Diamond and Sigmundson, 1997).
The standard, or traditional, approach, based on John Money’s earlier model, hypothesized that nurture influences far outweighed nature influences, and it was based on two criteria: that the gender needed to be established early (no later than 18 months), and the external genitalia must be compatible with the sex of rearing (Blizzard, 2002). However, 50 years later, science has learned that imprinting of the brain by testosterone and/or other androgens (steroid hormones that stimulate or control the development and maintenance of masculine characteristics) occurs to a greater extent than previously believed (particularly by Money). This has been evidenced in large part by the disproportionate number of intersex males raised as females, but whose etiology was not complete androgen insensitivity, elected to reassign themselves as males when they reached adolescence or adulthood (Blizzard, 2002).
In the United States, intersex is a recognized medical condition, but not a recognized societal designation. Regardless, the pediatric researchers Diamond and Sigmundson recommend that no surgeries be done for purely cosmetic purposes, though this is difficult to explain to parents who just want a “normal” child. Surgery as infants can drastically affect post pubertal sensitivity and function of the genitalia. They recommend a moratorium on any such gender “assignment” surgeries until at least adolescence, when the patient is able to give a truly informed consent (Diamond and Sigmundson, 1997). In addition to this, they suggest ongoing counseling, peer support, and consistency by the parents, in whatever role they choose to assign to the child, regardless of the appearance of genitalia, but it’s imperative that a gender be chosen, as opposed to raising the child as a “neuter” (Diamond and Sigmundson, 1997). There is the fear, however, that designating a gender without altering the genitals to match only reinforces stereotypes and makes the normative developmental processes that much more challenging for children and adolescents. Too many parents become too preoccupied with ensuring that their children stay within the “correct” gender guidelines of their designation, and it leaves little room for the child to explore options related to their gender identity and sexual orientation (Lev, 2006).
Due to its heavy ethical and practical complications, the study of gender assignment has been dubious and more hypothetical than actual (Lev, 2006). Although John Money vigorously counseled against sex reassignment after toddler age, due to the brain being (in his belief) highly malleable at birth in terms of gender identity, very little progress has actually been made in recent years in regards to understanding what determines gender identity. Gender identity is a highly complex biological and psychological process, and the relationship between prenatal biological processes and postnatal psychological influences is still under serious review. Very little long-term clinical data currently exists to help facilitate the understanding of the relative importance of prenatal and postnatal influences (Phornphutkul, Fausto-Sterling, and Gruppuso, 1999).
The study of, and treatment methods for, intersex children are highly contentious subjects. It is not always clear that everyone involved wants what’s best for the intersex individual, as gender politics and future reputations of the doctors play a large role. In most cases, genital “correction” is performed for purely aesthetic purposes, even though the physical health of the child is rarely, if ever, at risk. Future fertility potential for women, and the means to try to steer the direction of sexual desire in a concretely heterosexual direction (as one of the main fears cited by parents of intersex infants is that they will grow up to be gay) are two of the largest factors in determining the current protocols (Holmes, 1995, as cited in Lev, 2006).
The jury is still out on what is the best avenue of treatment, but as more and more longitudinal studies are being performed on intersexed individuals, a common consensus is growing that surgery to infants is not only a bad idea physically, but more importantly, grossly disrupts and upsets the normal psychological development of children and adolescents.
It is highly unlikely that all operations on ambiguous genitalia will cease, as most doctors, and parents, quite adamantly want to “normalize” their child and move on, probably even foregoing much counseling once it seems everything will be “fine.” But the fact that 24% of intersexed adults eventually reverse their gender isn’t a fact that can, or should, be easily ignored (Preves, 2003, cited in Lev, 2006).
Rather than help solve the nature versus nurture argument, this topic seems to more acutely exacerbate the arguments both for and against both nature and nurture. One would be hard-pressed to concretely state, based on the overwhelming evidence, that simply having the genitals of one gender or another makes you that gender. All factors of conditioning and biology come into play, but ultimately, one has to ask what, exactly, a gender identity is, and if that is determined by biology (that is, the physical self), conditioning, or some combination of the two.
It is my hope that in the near future, as intersexuality begins to come out of the closet, so to speak, that it is a topic more people will be more comfortable speaking about. Just in the last few years, it has practically become a cultural phenomenon: numerous articles have been written on the subject in major publications such as The New York Times; a Pulitzer Prize-winning novel has been written about the subject (Middlesex, by Jeffrey Eugenides), and numerous intersexed and transgendered characters are popping up all over the large and small screen in movies like The Crying Game, The Adventures of Sebastian Cole, and Transamerica, alongside top-rated television shows like Nip/Tuck. These presentations might seem trivial or sensationalistic, but any way of getting them into the public consciousness will eventually reduce the fear and stigma attached, and hopefully eventually turn into more mature and sympathetic presentations.

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