Disorders of sexual development are a heterogeneous group of disorders in which chromosomal, gonadal or anatomical sex development is atypical. The majority of these children are recognized at birth by ambiguous genitalia. Legal and societal pressures require the physician and parents to assign sex rapidly. Though sex assignment is undebated in several disorders of sexual development, many others need an individualized approach to gender-related concerns. Gender dysphoria is prevalent in disorders of sexual development, and early gender-defining surgeries have potentially (...) lifelong consequences. We use two cases, one of partial androgen insensitivity and another of simple virilizing congenital adrenal hyperplasia to illustrate that in disorders of sexual development, the ethical management principles remain the same at their core despite the vast differences in phenotypes. Sex assignment should maximize functional, psychological and sexual needs. Sex assigned should coincide with gender identity. We propose that we manage such children with the mutual participation of the physician, parents and the child. Though the parents and the physician have the child's best interests when making a decision, the child's developing autonomy should be protected. The communication of the health provider to the parent must be honest if early sex assignment is difficult. (shrink)

This article presents the Islamic bioethical deliberation on the issue of sex assignment surgery for infants with disorders of sex development or intersexed as a case study. The main objective of this study is to present a different approach in assessing a biomedical issue within the medium of the Maqasid al-Shari’ah. Within the framework of the maqasidic scheme of benefits and harms, any practice where benefits are substantial is considered permissible, while those promoting harms are prohibited. The concept (...) of Maqasid al-Shari’ah which is the mechanistic interpretation of Qur’an and Hadith presents the holistic attention of Islam on many life activities, including healthcare. Indeed, this concept encompasses many aspects of worldly life, both for the human individual and collectively for the whole society. In healthcare, the practice of SAS on DSD newborns has presented an assortment of implications on the future livelihood of the affected individual. The process of decision-making seems to be very multifaceted since every element such as the determination of the ‘correct’ sex and the urgency of early surgery must consider the benefits and harms, as well as the child’s rights and best interest. The application of the concept of Maqasid al-Shari’ah, would convey a pragmatic approach that is often disregarded in Western medicine. This approach considers the right of the individual to live life optimally, individually and socially and practice his faith, precisely, in accordance with the assigned gender. (shrink)

This article aims to analyse a possible manner of approaching the birth of intersexual children. We start out by summing up what intersexuality is and how it is faced in the dominant clinical practice. We then argue against this paradigm, in favour of a postponement of genital surgery. In the second part of this paper, we take into consideration the general question of whether only two existing sexes are to be recognized, arguing in favour of an expansion of sex (...) categories. In the third part, we illustrate the reasons supporting provisional sex attribution: the child’s best interest and respect for their developing moral autonomy. This position aims to increase the child’s well-being and self-determination, limiting parents’ freedom to take decisions on behalf of others, in particular, those decisions concerning basic aspects of their children’s personal identity. (shrink)

Few parents-to-be consider that their child may be born with ambiguous sex. Still, parents of a newborn child with ambiguous sex are expected to make a far-reaching decision for the child: should the child be operated upon so that it has either female or male genitals? The aim of this article is to examine, phenomenologically, why parents decide to have their children undergo genital surgery when it is not necessary for the child’s physiological functions. Drawing on phenomenological work by (...) Maurice Merleau-Ponty, Simone de Beauvoir and Sara Ahmed, we examine parents’ frustration when their child’s sex is ambiguous and their experiences of the practice of medical sex assignment. We also examine parental identity work when the child has been assigned a sex and the interaction between parents and medical professionals when parents make decisions regarding surgery on their child. Furthermore, we provide a critical perspective on the surgical practice. (shrink)

When the benefits of surgery do not outweigh the harms or where they do not clearly do so, surgical interventions become morally contested. Cutting to the Core examines a number of such surgeries, including infant male circumcision and cutting the genitals of female children, the separation of conjoined twins, surgical sex assignment of intersex children and the surgical re-assignment of transsexuals, limb and face transplantation, cosmetic surgery, and placebo surgery.

This article argues for a ban on the performance of medically unnecessary genital normalizing surgeries as part of assigning a binary sex/gender to infants with intersex conditions on the basis of autonomy, regardless of etiology. It does this via a dis/analogy with the classic case in bioethics of Jehovah Witness (JW) parents' inability to refuse life-saving blood transfusions for their minor children. Both cases address ethical medical practice in situations where parents are making irreversible medical decisions on the basis of (...) values strongly held, identity, and relationship-shaping values—such as religious beliefs or beliefs regarding the inherent value of binary sex/gender—amidst ethical pluralism. Furthermore, it takes seriously—as we must in the intersex case—that the restriction of parents' right to choose will likely result in serious harms to potentially large percentage of patients, their families, and their larger communities. I address the objection that parents' capacity to choose is restricted in the JW case on the basis of the harm principle or a duty to nonmaleficence, given that the result of parent choice would be death. I provide evidence that this is mistaken from how we treat epistemic uncertainty in the JW case and from cases in which clinicians are ethically obligated to restrict the autonomy of nonminor patients. I conclude that we restrict the parents' right to choose in the JW case—and should in the case of pediatric intersex surgery—to secure patient's future autonomy. (shrink)

When the benefits of surgery do not outweigh the harms or where they do not clearly do so, surgical interventions become morally contested. Cutting to the Core examines a number of such surgeries, including infant male circumcision and cutting the genitals of female children, the separation of conjoined twins, surgical sex assignment of intersex children and the surgical re-assignment of transsexuals, limb and face transplantation, cosmetic surgery, and placebo surgery.

Intersexual infants and infants with other genital abnormalities often receive genital surgery for sex assignment or for normalizing purposes. The wisdom and beneficence of these practices have been questioned by intersexual individuals, support groups, some doctors, and the media. Because the practices have been developed without long-term studies to evaluate them, pediatric urologists and parents of such children must face decisions with very little guidance from empirical support. In the face of ignorance about what is really the best (...) medical response to intersexuality or genital abnormalities, some have argued for a moratorium on infant genital surgery until empirical studies are available. The urgent need for retrospective studies is now being recognized in medical journals. Because genital surgery may be appropriate and beneficent in some of these conditions, or in some degrees of these conditions, but not in others, retrospective studies must be devised to examine the degree of success of surgery for each of these conditions, or levels thereof. (shrink)

Technological advances in the field of medicine and health sciences not only manipulate the normal human body and sex but also provide for surgical and hormonal management of hermaphroditism. Consequently, sex assignment surgery has not only become a standard care for babies born with genital abnormalities in the West but even in some Muslim states. On the positive side, it goes a long way in saving children born with abnormal genitalia from numerous legal interdictions of the pre-sex corrective (...) surgery. Nevertheless, the larger ethical and legal questions that medical management of genital abnormality raises to some extent have not been adequately appreciated by contemporary Muslim responses. This article, therefore, in principle argues against surgical management of intersexuality during early infancy from the Islamic legal perspective. (shrink)

Gender dysphoria in children has become a hot-button topic; however, clinical data still remain sparse on the effects of hormone therapy and transitional surgery on the physical and psychological well-being of those children. The American College of Pediatricians cites studies indicating that anywhere from 77 to 94 percent of boys and 73 to 88 percent of girls desist in GD; that is, following puberty the majority of children who experience GD will identify with their assigned biological sex. After reviewing (...) the clinical studies, this paper addresses the notion of gender from a Thomistic perspective, locating gender as a differentiation in the matter of the person flowing from the essence of the soul, resulting from the power of generation as opposed to other differences such as sight, which functions the same regardless of material differences. As a result, the paper concludes that hormone therapy cannot be morally licit for children. (shrink)

Intersex being a birth impairment in human babies is a fact of humanprecreation. Opposed to normal birth of humans as males and females incidentsof babies with vague gender identity have perturbed people and families asto how to socially place them within the binary system of men and womenin the community. In Islam, it is more important in view of the genderedorientation of some Islamic laws and its system of social ethics. Accordingly,jurists formulated an Islamic blueprint to manage this segment. However,their (...) main criteria to align such individuals to one of the normal genders wereinadequate to assign a specific sex to all intersex. Medical science, on the otherhand, proposes not only to achieve precise diagnoses of intersex conditionsbut also to manage them medically. Accordingly, Muslim jurists and muftisby and large celebrated this medical solution as a better remedy to resolve thisjuridical perplexing question. This study, however, argues that juristic stamp ofapproval needs to be more ethically grounded so as to avoid pitfalls inherent inthis medical innovation. (shrink)

Male-to-female transsexualism manifests itself in the form of a discrepancy between the male sex assigned at birth and the subjective experience of belonging to the female gender, which in many cases also involves a somatic transition by cross-sex hormone treatment and genital surgery. Until now, no studies related to MtF transsexualism have been carried out within the framework of a phenomenological/existential approach. This paradigm would make it possible to better articulate the transsexual experience beyond the simplistic diagnostic criteria by (...) which it is currently defined. In this study, I will reread MtF transsexualism in the light of Ludwig Binswanger’s theories on Mannerism and Jean Paul Sartre’s remarks on the self and the body. I will do this largely by focusing on first-hand accounts of the MtF transsexual’s experience, in other words from a first-person viewpoint. Finally, I will present some considerations on the meaning of psychological intervention in this field. (shrink)

Sex reassignment surgery is a therapy for gender dysphoria standardly provided only upon a psychiatric authorization. Transgender scholars criticize this practice as unjustified medicalization and stigmatization of transsexual people. By demanding that sex reassignment surgery is not classified as therapy, they imply it should be classified as some kind of a biomedical enhancement. It is argued in this article that this reclassification is empirically and morally implausible because sex reassignment surgery is incompatible with two major views of (...) enhancement. It is incompatible with the nontherapeutic view because it does not improve or augment, above average, any physical or mental trait or function. It is incompatible with the welfarist view because this view, contrary to the transgender scholars’s demands, is compelled to retain the standard practice of providing sex reassignment surgery in order to ensure the optimal balance between its availability, beneficence, and possible harmfulness. (shrink)

Catholic health care institutions presently face the question of whether it would be morally legitimate for them to participate in sex reassignment surgery for patients suffering from gender dysphoria. This essay replies to two articles published on this question in the Winter 2016 issue of the Catholic health care journal Health Care Ethics USA. It argues that both articles fail to attend to factors necessary for an adequate moral assessment of the question, and thus provide inadequate solutions. It goes (...) on to argue that it would be intrinsically wrong for Catholic hospitals to counsel or perform sex reassignment surgery if in so doing they affirmed certain widely held erroneous assumptions about the nature of sex and gender. The essay ends by asking whether, if those erroneous assumptions were clearly and publically rejected, it could ever be licit to per­form surgical amputations or plastic surgical reconstructions to assist persons suffering from severe and intractable cases of gender dysphoria. (shrink)

Dialogue about the moral permissibility of sex reassignment surgery (SRS) in Catholic health care has recently received considerable attention. In an effort to further this discussion and bring clarity to the debate, the author uses Pope St. John Paul II’s robust theological and philosophical anthropology to evaluate the morality of SRS and enter dialogue with current arguments that suggest SRS is morally licit. The author argues that John Paul II’s anthropology renders SRS morally illicit. Moreover, current arguments supporting SRS (...) rely on an anthropology of body–soul dualism. This conclusion suggests that future arguments for the permissibility of SRS in Catholic health care will always be invalid if they fail to uphold the body–soul unity of the person. (shrink)

Sex reassignment surgery raises a number of ethical questions. This article examines a few of these questions through the lens of Karol Wojtyla’s philosophical anthropology. The author maintains that the operation is based on a dualistic view of the person and a distorted understanding of the human capacity for self-determination. In his work, Wojtyla emphasizes the inseparable connection between freedom and truth, and he argues that the person is a unity of body and spirit, so that the body cannot (...) be reduced to mere matter. Therefore, the author concludes that sex reassignment surgery must be seen as morally illicitin light of Wojtyla’s anthropology. National Catholic Bioethics Quarterly 9.4 (Winter 2009): 711–723. (shrink)

Is it ethical to perform a surgery whose purpose is to make a male look like a female or a female to appear male? Is it medically appropriate? Sexual reassignment surgery (SRS) violates basic medical and ethical principles and is therefore not ethically or medically appropriate. (1) SRS mutilates a healthy, non-diseased body. To perform surgery on a healthy body involves unnecessary risks; therefore, SRS violates the principle primum non nocere, “first, do no harm.” (2) Candidates for (...) SRS may believe that they are trapped in the bodies of the wrong sex and therefore desire or, more accurately, demand SRS; however, this belief is generated by a disordered perception of self. Such a fixed, irrational belief is appropriately described as a delusion. SRS, therefore, is a “category mistake”—it offers a surgical solution for psychological problems such as a failure to accept the goodness of one’s masculinity or femininity, lack of secure attachment relationships in childhood with same-sex peers or a parent, self-rejection, untreated gender identity disorder, addiction to masturbation and fantasy, poor body image, excessive anger, and severe psychopathology in a parent. (3) SRS does not accomplish what it claims to accomplish. It does not change a person’s sex; therefore, it provides no true benefit. (4) SRS is a “permanent,” effectively unchangeable, and often unsatisfying surgical attempt to change what may be only a temporary (i.e., psychotherapeutically changeable) psychological/psychiatric condition. National Catholic Bioethics Quarterly 9.1 (Spring2009): 97–125. (shrink)

Surgeons who perform sex reassignment surgeries define their goals and evaluate their outcomes in terms of two kinds of results: aesthetic and functional. Since the neogenitals fashioned through sex reassignment surgeries do not enable reproductive function, surgeons must determine what the function of the genitals is or ought to be. A review of surgical literature demonstrates that questions of what constitute genital form and function, while putatively answered in the operating room, are not answerable in the discourses of clinical evaluation (...) used to define them. When the genitals—the word itself derived from the Latin genitas meaning to beget—are not reproductive, the question of their function shifts away from the biological and into other registers: pleasure, intimacy, sociality. As condensed sites of meaning and meaning-making around which selves, affects, resources, anxieties and futures are organized, the genitals signify in excess of the categories of “aesthetic” and “function” that surgeons use to assess them. Not reducible to either aesthetics or function, but constitutive of them both, this excess appears in surgical texts in the form of imagined futures of social and sexual engagement and demonstrates a powerful means by which properly sexed bodies are created. (shrink)

The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent British Medical Association guidance from 2019. We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital (...) cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision making regarding therapeutic options for a medically unwell patient—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a healthy child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards being applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children's genitals before they can meaningfully participate in the decision. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Finding My Compass*Laura Inter+I was born in the 1980s, and much to my parents surprise, the doctors could not say whether I was a boy or a girl because my body had ambiguous genitalia. They then conducted a chromosome test and the result was XX chromosomes. I was assigned female and only later was diagnosed with congenital adrenal hyperplasia (CAH). Fortunately for me the endocrinologist who treated me did (...) not mention the option of surgery, so my medical treatment consisted only of taking cortisol. Apart from this, from the time I turned one, I was subjected to genital examinations twice a year, during which the endocrinologist would touch my genitals and look to see how they were developing.These unnecessary and intrusive examinations had a profound effect on me. As a young child, I did not understand why I had to lower my pants in front of a stranger—the endocrinologist—and let him touch me. The fact that my mother was present, and approved of this was something that made me feel completely helpless. All this seemed very strange to me; I found it confusing, and terribly uncomfortable, and I just felt it wasn’t right.I remember the doctor always spoke as if I wasn’t right there, and I did not always understand everything the doctor said when I was young, because of all the medical terms he used. I grew up with a feeling of being “inadequate,” of having a sense that something was wrong with me, though I didn’t know exactly what. These exams lasted until I was about 12 years old. Years later, as I began my adult, sexual life, I realized how much those displays had affected me emotionally.I discovered what was “wrong” with me during sex education classes in the first year of high school. There was a class session in which two images were shown: one displaying the external female sex organs, and the other the male sex organs. I noticed that my body was not like either of them. I was very distressed, thinking “I have deformed genitals!” I feared I could not perform sexually as either a man or a woman. I became very depressed. I was sure nobody would want me, that I would never have a relationship. I was unacceptable, “abnormal,” or at least that is what the doctors had said. And in any case my parents never spoke of it, and I didn’t know that I had CAH.Skip forward a few years: I was still looking for answers, I found my medical file and read in the documents “pseudo–hermaphrodite,” and [End Page 95] “congenital adrenal hyperplasia.” I searched the internet, but only found medical opinions that said that in the case of genital ambiguity, the best option was surgery. I wondered to myself: “Why didn’t they operate on me?”I put the question to my parents, and, at fifteen, I found myself being examined once more in the doctor’s office, this time to consider the possibility of a genital surgery which might once and for all, I believed, make me a “normal” person.I have never told anyone outside my family before, but one of those exams was the most humiliating experiences of my life. One doctor wanted to speak with me alone, so she made my mother wait outside the exam room. My mother agreed, thinking that after the doctor talked with me, my mother would be able to be present during the rest of the exam. The doctor asked me questions, some of which made me very uncomfortable: “Do you feel good about being a woman”? Did you ever feel like a man? Why don’t you dress up more, use more makeup? Are you a lesbian? Have you ever had sex? She then said she wanted to see my genitals. I felt awful and wanted my mother present, but I also wanted it to be over quickly, and said nothing. Examining my genitals, the doctor told me they “would not be adequate for sex,” and that she needed to “perform surgery.” Something else that made me uncomfortable was the presence of another doctor in... (shrink)

Wir diskutieren ethische Probleme der medizinischen Behandlung intersexueller Kinder. Gefragt wird nach dem Stellenwert von Elternwünschen nach eindeutiger Geschlechtszuweisung sowie nach den Konfliktfeldern, die zum einen zwischen konkurrierenden Wunschvorstellungen der Eltern und der behandelnden Ärzte, zum andern zwischen Kindeswohl und Kinderrechten entstehen können. Gegenwärtig wird Neugeborenen mit anatomisch uneindeutigem Genital trotz unsicherer Prognose über die Behandlungsergebnisse oft noch ein Geschlecht zugewiesen und operativ erstellt. Dieses Vorgehen ist von verschiedenen Seiten ethisch heftig kritisiert worden. Kipnis u. Diamond forderten 1998 im „Journal (...) of Clinical Ethics“ ein Moratorium für alle nicht vital indizierten geschlechtskorrigierenden Eingriffe. Diese Forderung orientiert sich am Interesse des zukünftigen Erwachsenen, betont dessen prospektive Autonomie und klammert den Elternwunsch aus. Dieses „Modell des antizipierten Konsenses“ kann jedoch mit Bezug auf Neugeborene und Kleinkinder bedeutsame Aspekte des Eltern-Kind-Verhältnisses nicht angemessen erfassen. Im Aufsatz werden Argumente angeführt, die es aus Sicht einer Ethik der Elternschaft rechtfertigen, ethische Entscheidungen auf der Basis eines beziehungsorientierten Modells zu treffen. In unserem Modell fallen Elternwünsche ethisch ins Gewicht. (shrink)

Wir diskutieren ethische Probleme der medizinischen Behandlung intersexueller Kinder. Gefragt wird nach dem Stellenwert von Elternwünschen nach eindeutiger Geschlechtszuweisung sowie nach den Konfliktfeldern, die zum einen zwischen konkurrierenden Wunschvorstellungen der Eltern und der behandelnden Ärzte, zum andern zwischen Kindeswohl und Kinderrechten entstehen können. Gegenwärtig wird Neugeborenen mit anatomisch uneindeutigem Genital trotz unsicherer Prognose über die Behandlungsergebnisse oft noch ein Geschlecht zugewiesen und operativ erstellt. Dieses Vorgehen ist von verschiedenen Seiten ethisch heftig kritisiert worden. Kipnis u. Diamond forderten 1998 im „Journal (...) of Clinical Ethics“ ein Moratorium für alle nicht vital indizierten geschlechtskorrigierenden Eingriffe. Diese Forderung orientiert sich am Interesse des zukünftigen Erwachsenen, betont dessen prospektive Autonomie und klammert den Elternwunsch aus. Dieses „Modell des antizipierten Konsenses“ kann jedoch mit Bezug auf Neugeborene und Kleinkinder bedeutsame Aspekte des Eltern-Kind-Verhältnisses nicht angemessen erfassen. Im Aufsatz werden Argumente angeführt, die es aus Sicht einer Ethik der Elternschaft rechtfertigen, ethische Entscheidungen auf der Basis eines beziehungsorientierten Modells zu treffen. In unserem Modell fallen Elternwünsche ethisch ins Gewicht. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Promoting Health and Social Progress by Accepting and Depathologizing Benign Intersex TraitsHida ViloriaI was born with ambiguous genitalia and it was a doctor who, by honoring my bodily integrity and not “fixing” me, gave me the greatest gift I’ve ever received. Because my body and its sexual traits are a positive, fundamental part of my experience and identity as a human being, I know that having my genitals removed (...) or altered according to someone else’s vision would have deeply damaged me, both physically and psychologically.The doctor who protected my autonomy was, unsurprisingly, my father. I say “unsurprisingly” because in my experience parents are typically more protective of their children than doctors are of their patients. Also, doctors do not discuss cases with other doctors in the same way they do with laypeople, as doctors know more about medical issues such as the risks involved in infant genital surgery.Other than having clitoromegaly (a large clitoris), my reproductive anatomy is typically female, and so I was assigned female and raised as such without incident. My parents didn’t discuss my intersex traits with me, and I grew up thinking of myself and being accepted as, a girl.When I began menstruating, my father told me I’d need to take pills to “grow taller.” I thought this unusual, as I wasn’t short, and later overheard my mother arguing with him, saying that the pills were “experimental”. I was reminded of this discussion years later, when she told me that the pills had actually been hormones to make my breasts grow. I never took them though as she convinced my father not to make me.Article 7 of The International Covenant on Civil and Political Rights states that, “No one shall be subjected without his free consent to medical or scientific experimentation,” and I’m grateful to both my parents for protecting my civil rights as they protected my health.Due to my Catholic upbringing and schooling, I had no opportunity to compare my genitals to other girls’, and it wasn’t until the age of twelve that I realized, while perusing magazines with friends, that I have atypical sex anatomy. Contrary to common speculation however, this awareness didn’t make me question being female. I simply assumed there must be some genital variation in humans.I feel my parents made the wisest decision possible by registering me as one of the two accepted, available genders but allowing me to live, physically and behaviorally, as who I am. Despite not having developed a stereotypically curvaceous female figure, I was popular and excelled in typically feminine social activities, as well as sports and academics. For example, I was one of four girls selected out of one hundred twenty–five that competed for a spot on my high school cheerleading [End Page 114] squad when I tried out to help a friend who needed a tryout partner.Other than escaping IGM (Intersex Genital Mutilation) and estrogen therapy, I’ve had only a few experiences pertaining to my medical care around being intersex. These experiences fall into two categories: seeing medical doctors who treated me the same after discovering that I have ambiguous genitalia, and seeing ones who didn’t. I feel incredibly blessed that my experiences in the former category vastly outweigh the latter.My first experience came at the age of twenty, when a gynecologist asked me if my clitoris had always been as large as it is. I responded that it had, and she said, while looking at me disapprovingly, that she’d like to do some tests. When I asked her what they were for though, she wouldn’t respond directly. She said I’d reported having some upper lip hair, and acne, on my intake forms. I replied that neither were above average, and asked if there were health issues I should be concerned about. She reluctantly said no. I asked what reason there was then for undergoing tests because of the size of my clitoris.She finally responded, “It’s just not normal.”Fortunately, I’d had positive reactions to my sex traits from the people I’d dated. For example, the first... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Michael’s Story or the Paradox of NormalcyMichael KreuzerI was born in Montreal in 1974. My parents were both “older.” My mother was almost 45; my father was in his 50’s. I have a sister who is six years older than me. What I know about my mother’s prenatal care is that it was quite basic.I was premature. My mother’s due date was in mid–August, however I showed up about (...) three weeks earlier. I know that initially upon my birth I was declared male. However, upon closer examination, a few “abnormalities” of my genitals were found. I urinated through a small hole at the base of my penis; adjacent to this hole was another opening, barely big enough for a Q–tip. My scrotum was empty; my gonads had not descended.The doctors who examined me decided that they could not assign a gender without further testing. They told my mother I would need to remain in the hospital until such testing was completed. Apparently not being able to determine sex/gender is a life–threatening condition that requires hospitalization.It was determined that I had a uterus and it was presumed that my undescended gonads were ovaries (not verified by biopsy). There was a small vaginal opening behind my small urethral opening. Structures such as the labia were not developed. I found out later my vagina had fistulated into both my urethra and my perineum. Karyotyping was performed resulting in 46,XX with a diagnosis of female pseudo–hermaphroditism. My parents were informed that in spite of my external genitalia I was female and I would never develop as a male. I would require “corrective surgeries” which should be performed as soon as possible so I would not have any issues with my gender identity. They were even told that I would be able to become pregnant if I had the surgeries. In fact, I never ovulated and I have a small unicornuate uterus.My father refused all surgeries on my behalf most likely because he was a full–blooded Navajo who had suffered from abuse in an Indian boarding school during his childhood in New Mexico. His family was traditional, and because they didn’t adapt to prevailing Christian values, he and several of his siblings were removed from their parents. My dad was the oldest of 12 children and by the time his youngest siblings were born, the practice to take children away from their families had been changed.I think my father was deeply traumatized by his childhood and did not associate much with his family, nor did he want to visit the reservation. He spoke the language but never encouraged us to learn it. He did teach us some of the traditions. He told me about the nadleh, which is the other gender besides male and female in the Navajo tradition. There are two kinds of nadleh, which are almost like male–to–female and female–to–male transsexuals. Mostly I educated myself later and learned about the Navajo belief system in which the creation story is an important part. In the Navajo tradition, the creation story tells of First Man and First Woman; the first children born to them are the Hermaphrodite Twins. [End Page E7]My father was a US Army Master Sergeant, which was an unusual career for a man of his origins; he was a veteran of the Second World War. After he left the army he took his family to Montreal where he had a job in security. I think he preferred to live outside the U.S. He used to say that in Germany, where he had managed to stay for a long time while serving in the Army, he was just another American soldier. In spite of his career, he had a deep mistrust for “white people.” I remember he used to say that he was in the Army because this was his country long before the white people came and he loved it. He did not love the people who governed it. All this very much played into the decision not to listen to the doctors’ recommendations about surgery. My... (shrink)

Objective: To examine students’ attitudes and potential behaviour to a possible intimate relationship with a patient as they pass through a modern medical curriculum.Design: A cohort study of students entering Glasgow University’s new learner centred, integrated medical curriculum in October 1996.Methods: Students’ pre year 1 and post year 1, post year 3, and post year 5 responses to the “attractive patient” vignette of the Ethics in Health Care Survey instrument were examined quantitatively and qualitatively. Analysis of students’ multi-choice answers enabled (...) measurement of the movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes on students’ reasoning behind their decision to enter a relationship or not were also identified.Results: No significant movement towards consensus was found at any point in the curriculum. There was little improvement in students’ performance in terms of knowledge content and their abilities to recognise the values inherent in the vignette. In deciding to enter a relationship with the patient the most frequently used reasoning was that it could be justified if the patient changed their doctor.Conclusions: Teaching on the subject of sexual or improper relationships between doctors and patients, including relationships with former patients requires to be made explicit. Case based teaching would fit in with the ethos of the problem based, integrated medical curriculum. (shrink)

Since the late 1980s, intersex adults and activists have critiqued the clinical recommendations defined in the 1950s to treat children born with ‘ambiguous genitalia’ with normalising medicine. While their struggles continue, in particular to halt the practice of genital surgery in early infancy, some European surgeons travel to African countries to transfer standards of care that have become highly controversial in the North, including in the medical community. Simple disapproval of these tours as ‘surgical safaris’ forecloses the possibility of (...) analysing more complex situations in which the so-called transfer of competence involves surgeons who promote ‘less cutting and more talking’. Such is the case – and the interest – of the surgical missions in West Africa in which I conducted recent fieldwork, accompanying a team of paediatric surgeons from a European university hospital collaborating with a renowned international NGO. This article analyses the ways in which a variation of sex development called hypospadias is framed and managed in this context through what I call a surgical script for hypospadias. I examine the conditions of (im-)possibility for Northern surgeons to operationalise, and sometimes revise, this script at the missions (but also closer to home). I discuss what the surgeons do in practice to reflect critically on the normative work of the surgical script for hypospadias as a social script on morphological ideals of sex, gender and reproductive heterosexuality. I consider in what sense genital surgery can be said to (re-)construct ‘normal’-looking genitalia, but also, fundamentally, the very idea of genitalia. (shrink)

On imagine trop souvent que les caractères " naturels " (le sexe, la race, par exemple) " tombent sous le sens ", sont des évidences inquestionnables. Tout au plus admet-on que les sociétés manipulent un peu tout cela, qu'il en résulte des différences, bonnes ou mauvaises, c'est selon... Pourtant, ne serait-ce pas déjà une manipulation que de prétendre certains caractères " naturels "? Le " naturel " ne serait-il pas une interprétation, bref un " artifice ", ancré dans de très (...) particulières relations sociales où certains sont assignés à l'état d'objet? Cet ouvrage associe la description d'une réalité matérielle quotidienne dans ses formes les plus banales (conversations de bistrot, scènes de rue, faits divers) et l'analyse précise des systèmes idéologiques qui prétendent expliquer cette réalité. (shrink)

Carol Bayley’s double-effect reasoning in defense of sex-reassignment surgery fails at the opening. The first condition of the principle is that the act in itself must be morally good or at least neutral. She says, without argument, “the surgery itself is neutral.” How so? The surgery is a direct assault on the physical integrity of a person whose sexual organs are perfectly healthy. Is it reasonable to say that a person who wants to change gender has a (...) body that is in fact seriously deformed or diseased? Where is the evidence? If reality is defined by the mind, then the imagination may freely think of personal identity in any conceivable way. Nature is set aside and in its place is put, at best, a delusion and, at worst, an ideology that seeks to do violence to nature. Catholic hospitals should not participate in this assault upon God’s creation. (shrink)

People often assume that everyone can be divided by sex/gender (that is, by physical and social characteristics having to do with maleness and femaleness) into two tidy categories: male and female. Careful thought, however, leads us to reject that simple ‘binary’ picture, since not all people fall precisely into one group or the other. But if we do not think of sex/gender in terms of those two categories, how else might we think of it? Here I consider four distinct models; (...) each model correctly captures some features of sex/gender, and so each is appropriate in some contexts. But the first three models are inadequate when tough questions arise, like whether trans women should be admitted as students at a women’s college or when it is appropriate for intersex athletes to compete in women’s athletic events. (‘Trans’ refers to the wide range of people who have an atypical gender identity for someone of their birth-assigned sex, and ‘intersex’ refers to people whose bodies naturally develop with markedly different physical sex characteristics than are paradigmatic of either men or women.) Such questions of inclusion and exclusion matter enormously to the people whose lives are affected by them, but ordinary notions of sex/gender offer few answers. The fourth model I describe is especially designed to make those hard decisions easier by providing a process to clarify what matters. (shrink)

Is sex identity a feature of one's mind or body, and is it a relational or intrinsic property? Who is in the best position to know a person's sex, do we each have a true sex, and is a person's sex an alterable characteristic? When a person's sex assignment changes, has the old self disappeared and a new one emerged; or, has only the public presentation of one's self changed? "You've Changed" examines the philosophical questions raised by the phenomenon (...) of sex reassignment, and brings together the essays of scholars known for their work in gender, sexuality, queer, and disability studies, feminist epistemology and science studies, and philosophical accounts of personal identity. An interdisciplinary contribution to the emerging field of transgender studies, it will be of interest to students and scholars in a number of disciplines. (shrink)

I offer a reconstruction of contemporary medical procedures of sex assignment for infants with intersex conditions. In the perspective adopted, sex assignment to intersexed newborns can be understood as a procedure that imposes determinate sex predicates. The account describes two stages of sex assignment. At the first stage of the process, the sex predicates ‘female’, ‘male’, or ‘intersexed’ are taken to denote genital morphology. Initial genital assessment of newborns imposes clear boundaries upon the extensions of these predicates (...) through diagnostic schemes of precisification. At the second stage, the sex predicates ‘female’ and ‘male’ denote sex of rearing, a therapeutic and pedagogical project aimed at producing stable and psycho-socially well-adjusted gender identity. The multi-dimensional indeterminacy of prognosticating sex of rearing at the second stage is mitigated through the prioritization of some subsets of the medical data. (shrink)

Biological sexes (male, female, hermaphrodite) are defined by different gametic strategies for reproduction. Sexes are regions of phenotypic space which implement those gametic reproductive strategies. Individual organisms pass in and out of these regions – sexes - one or more times during their lives. Importantly, sexes are life-history stages rather than applying to organisms over their entire lifespan. This fact has been obscured by concentrating on humans, and ignoring species which regularly change sex, as well as those with non-genetic or (...) facultatively genetic sex determination systems. But the general point applies equally to humans. Assigning sexes to pre-reproductive life history stages involves ‘prospective narration’ – classifying the present in terms of its anticipated future. Assigning sexes to adult stages of non-reproductive castes or non-reproductive individuals is a complex matter whose biological meaning differs from case to case. The chromosomal and phenotypic ‘definitions’ of biological sex that are contested in philosophical discussions of sex are actually operational definitions which track gametic sex more or less effectively in some species or group of species. Neither ‘definition’ can be stated for species in general except by defining them in terms of gametic sex. The gametic definition of sex also features in widely accepted models which explain why two biological sexes – either in separate individuals or combined in hermaphroditic individuals - are almost universal in multicellular species. Finally, the fact that a species has only two biological sexes does not imply that every member of the species is either male, female or hermaphroditic, or that the sex of every individual organism is clear and determinate. The idea of biological sex is critical for understanding the diversity of life, but ill-suited to the job of determining the social or legal status of human beings as men or women. (shrink)

This paper addresses the question, which sex ratio will evolve in a population that is subject to mutation and drift. The problem is analyzed using a simulation model as well as analytical methods. A detailed simulation model for the evolution of a population's allele distribution shows that for the sex ratio game a wide spectrum of different population states may evolve from on the one hand a monomorphic state with one predominant allele and with all other alleles suppressed by the (...) forces of selection, to on the other hand a polymorphism determined by recurrent mutations. Which of these states will evolve depends on the population size, the mating system and the rate of mutations. For the sex ratio game the evolutionarily stable strategy (ESS), as defined by evolutionary game theory, can only predict the population sex ratio but not the underlying stable population state. A comparison of different approaches to the problem shows that false predictions of the stable population states might result from two simplifying assumptions that are fairly common in evolutionary biology:a) it is assumed that mutations are rare events and there is never more than one mutant gene present in a population at any one time; b) a deterministic relationship is assumed between the fitness assigned to an individual's strategy and the individual's contribution to the gene pool of future generations. (shrink)

Transgender people have among the highest rates of suicide attempts of any group in society, driven strongly by the perception that they do not belong in the sex of their physical body. Gender reassignment surgery is a procedure that can change the transgender person’s physical body to accord with their gender identity. The procedure raises important ethical and distributive justice concerns, given the controversy of whether it is a cosmetic or medical procedure and the economic costs associated with performing (...) the procedure. This paper argues that there is a strong case for funding GRS as a matter of clinical necessity and justice. This paper will be divided in four key sections: First, the state of transgender health will be outlined, including the role of GRS and common objections to it. Second, a number of common objections to GRS will be analysed at the outset and shown to be unconvincing. Third, a constructive argument will be advanced, arguing that publicly funded GRS is clinically necessary, cost-effective, and demanded by principles of justice. Fourth, the paper will briefly discuss moralistic biases and why we demand a higher burden of justification for funding GRS compared with other analogous procedures. (shrink)

English law is unambiguous that legal personality, and with it all legal rights and protections, is assigned at birth. This rule is regarded as a bright line that is easily and consistently applied. The time has come, however, for the rule to be revisited. This article demonstrates that advances in fetal surgery and (anticipated) artificial wombs do not marry with traditional conceptions of birth and being alive in law. These technologies introduce the possibility of ex utero gestation, and/or temporary (...) existence ex utero, and consequently developing human beings that are novel to the law. Importantly, therefore, the concepts of birth and born alive no longer distinguish between human beings deserving of legal protection in the way originally intended. Thus, there is a need for reform, for a new approach to determining the legal significance of birth and what being legally alive actually encompasses. Investigating the law of birth is of crucial importance, because of the implications of affording or denying the subjects of new reproductive technologies rights and protections. A determination of the legal status of the subject of fetal surgery or an artificial womb will determine what can and cannot be done to each entity. Moreover, the status afforded to these entities will drastically impact on the freedoms of pregnant women. (shrink)

Autonomy is fundamental to liberalism. But autonomous individuals often choose to do things that harm themselves or undermine their equality. In particular, women often choose to participate in practices of sexual inequality—cosmetic surgery, gendered patterns of work and childcare, makeup, restrictive clothing, or the sexual subordination required by membership in certain religious groups. In this book, Clare Chambers argues that this predicament poses a fundamental challenge to many existing liberal and multicultural theories that dominate contemporary political philosophy. Chambers argues (...) that a theory of justice cannot ignore the influence of culture and the role it plays in shaping choices. If cultures shape choices, it is problematic to use those choices as the measure of the justice of the culture. Drawing upon feminist critiques of gender inequality and poststructuralist theories of social construction, she argues that we should accept some of the multicultural claims about the importance of culture in shaping our actions and identities, but that we should reach the opposite normative conclusion to that of multiculturalists and many liberals. Rather than using the idea of social construction to justify cultural respect or protection, we should use it to ground a critical stance toward cultural norms. The book presents radical proposals for state action to promote sexual and cultural justice. (shrink)

Until recently, cosmetic surgery was associated almost exclusively with women. However, men appear to be altering their appearance in increasing numbers. Both the media and the medical profession have seized upon this phenomenon as just one more example of the growing equality between the sexes, arguing that it is just a matter of time before men are having just as much cosmetic surgery as women. In this article, I take issue with the notion of the `new' sexual equality (...) in the realm of appearance and women and men's involvement in the practice of cosmetic surgery. To this end, representations of the male cosmetic surgery patient in the media and in medical texts will be analyzed. Drawing upon contemporary theories of masculinity, I will show why, contrary to popular belief, we have every reason to expect that cosmetic surgery will remain a predominantly feminine practice. (shrink)

I present the notion of epistemic injustice coined by Miranda Fricker and apply it to the situation of people with intersex traits, especially intersex children who are the subjects of “normalizing” surgery. Several studies from Polish hospitals show that both early “normalizing” surgery and the decision to postpone such surgery can result in harm to an intersex child. For this reason, I claim that “normalizing” surgery is only an expression of the epistemic hermeneutical injustice existing before (...) the surgery and that its source is the lack of an empirically adequate notion of sex characteristics. The binary notion is too simple to grasp intersex traits, and this epistemic dysfunction turns into practical harm. In contrast to Morgan Carpenter, I defend the nonbinary gender category as being important to limiting “normalizing” surgery. (shrink)