Science and medicine are not immune from social influence, and as a result are not necessarily culturally universal. In regards to sex and gender, social construction plays a meaningful but often hidden role in medicine, producing significant biases (Hubbard 1996). For many clinicians and laypersons functioning within the traditions of biomedicine, gender is understood through sexual dimorphism: that only two sexes, male and female, possess distinct biological characteristics which form gender identity (Herdt 1990). According to the pervasive Western ideology, these sexes come with specific traits, such as genetic markers and physical attributes, and are consequently assigned behavioral gender roles. The notions of distinctive gender and sex are deeply ingrained in the medical community and reinforced in everyday social interactions, to the extent that the idea of ambiguity is not only foreign, but distressing. Perceptions of the qualities that differentiate sex, influence and are influenced by, the social constructs of gender through many avenues, for instance, science, religion, popular culture, and so on. Thus, an examination of the cultural influences on sex and gender, including those present in biomedicine, is necessary to conceptualize ¿½real¿½ differences. In exploring how village cultures in Papua New Guinea and the Dominican Republic respond to intersexuality, the constructs of the dimorphic approach on the intersex individual and society can be better understood.
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Intersexuality, when used to categorize the physiological conditions which cause ¿½gender ambiguity¿½ of various kinds, may present in as many as 4 percent of live births (Fausto-Sterling 1993). These ambiguities include inappropriate virilization and variation in the presence and construction of inner and outer genitalia, varying in severity between and within the conditions that cause them (Kuhnle and Krahl 2002). In a biomedical system, the presence of sex-typed genitalia is used as the primary means to assign sex at birth, so infants with more visually apparent differences from the binary norm are recognized immediately and the assignment must wait for clinical intervention (Kuhnle and Krahl 2002). Individuals whose symptoms are less visually apparent at birth, for instance, an enlarged clitoris mistaken for a penis, atypical internal genitalia, or inappropriate virilization later in life, are subsequently not diagnosed at birth. Recognition of an abnormal condition comes much later for these patients, usually to the surprise of parents and practitioners.
It¿½s important to consider how biological reductionism as a social construct affects the understanding of sex and gender, because biological sex is not always cut and dry and is not necessarily clearly allocated to male or female by the presence, or lack, of certain hormones or the morphology of genitalia. How does a sexually dimorphic, biologically reductionist approach affect the treatment of intersex individuals? The reaction of the modern West has been to medicalize gender: to determine those attributes that seem to most clearly define one as male or female and, where nonnormative, to address the ambiguity through clinical means. Intersex becomes pathological, requiring diagnostic parameters and medical intervention. This medicalization suggests that there is a threshold for acceptable sex differentiation, but that an individual ought always to fit, as much as possible, into one category or the other. To this aim, research on intersexuality has produced a range of syndromes and attempts to accurately name them, a process which reinforces a medicalized view of gender and sex (Conrad 2007). When faced with anomalies in the biological determinants of sex, the clinician¿½s goal is to realize an ¿½optimal gender¿½ (Zucker 2002), which may or may not reflect an individual¿½s genetics or hormones. Assignment and treatment towards this ¿½optimal gender¿½ is determined using the following parameter: ¿½reproductive potential, good (i.e. heteronormative) sexual function, minimal medical procedures, an overall gender-appropriate appearance, a stable gender identity, and psychosocial well-being¿½ (Zucker 2002). It should be noted that popular science ideology stresses the ability of the patient to ¿½fit¿½ into either the male or female gender in regards to physical appearance as critical in achieving a ¿½stable gender identity¿½ and ¿½psychosocial wellbeing¿½, which negates the possibility that attempts to do so might in fact cause dysphoric gender identity. Using these considerations, invasive surgeries are performed in order to ¿½normalize¿½ external genitalia, typically accompanied by courses of hormone therapy in order to guide the physical development into the assigned gender (Berenbaum 2006). Since absence or underdevelopment of the phallic structure is typical of intersex genetic males, and it is more difficult to surgically create a functioning penis than a vagina, ¿½the majority of children born with ambiguous genitals are turned into girls¿½ (Hubbard 1996). Binary models of sex are reinforced, insisting on a definitive and unchanging view of sex and gender. Limiting notions of success in ¿½good sexual function¿½, a ¿½stable gender identity¿½, ¿½psychosocial well-being¿½, and insistence on genitalia that appears neatly masculine or feminine, serve to impose the Western cultural construct of sexual dimorphism upon the individual (Worthman 1995).
Not only are there variations in realization of the biological attributes assigned to sex differentiation, but also in the societal response to these sex differences, which serve to change and transform both gender and the concepts of it. It is here that the studies of intersex individuals in the Dominican Republic and New Guinea play an important part in understanding gender and sex conceptually and practically, by contrasting the lives of these individuals, who did not receive clinical diagnosis and care, with the binary Western convention of sex. Sexual dimorphism is called into question by the seeming presence of a third gender category (Herdt 1990). While first assumed to support popular applications of biological reductionism, the studies in fact offer documented flexibility between biological conditions and social environments in construction of gender identity (Herdt 1990). These studies are particularly appropriate to the discussion of medicalization because the affected individuals did not undergo permanent surgical alteration or hormone therapy, the two prevalent forms of treatment for the intersex in the West. Their life experiences reflect an opportunity to shift in and out of gender roles without contending with the irreversibility of these clinical methods.
The study conducted in the southwest Dominican Republic draws on narratives to form the sexual histories of 38 genetic males found to have steroid 5-alpha reductase hermaphroditism, a condition characterized by ¿½severe ambiguity¿½ (Imperato-McGinley, et. al. 1979). In cases of steroid 5-alpha reductase hermaphroditism, the development of the sex organs in utero is affected, resulting in underdeveloped external genitalia (Imperato-McGinley, et. al. 1979). However, increased presence of testosterone at puberty stimulates phallus growth, the presence of ejaculate, and, in many cases, descending of the testes (Imperato-McGinley, et. al. 1979). According to Imperato-McGinley, et. al., out of 18 cases of genetic males with steroid 5-alpha reductase hermaphroditism who were raised ¿½unambiguously¿½ as girls, 16 transitioned into ¿½a male-gender role¿½ after puberty (1979), although subsequent research has determined that in fact only 13 were ¿½observed to make a clear-cut sex role change¿½ (Herdt 1990).There was no medical intervention in early life, so the 16 males were able to physically and socially transform their gender role upon biological masculinization, more easily than if they had experienced feminizing surgeries and hormone therapy to supplement female-gendered rearing.
Surprisingly, there is little ethnographic data regarding the two subjects raised as girls who did not transition into a male gender role, or the 20 individuals who were raised as men (Herdt 1990). Subject 25 maintained her heterosexual female identity, denied sexual attraction to women, and expresses a strong desire for female assignment surgery (Imperato-McGinley, et. al. 1979). Likewise, Subject 4 continued to dress as a female, although researchers ultimately designate a male gender identity because the individual has the ¿½mannerisms of a man¿½ and engages in sexual relationships with women (Imperato-McGinley 1979). The social lives of the subjects reared male is largely underrepresented, although the assumption is relatively normative male development, which may not be accurate. The range of variety in the life experiences of these neglected subjects contradicts a strict interpretation of biological reductionism. While a majority of the genetic males did appear to assume a male-gender identity (regardless of rearing) there still persisted a strong female identity or conventional female behavioral roles in two out of thirty eight subjects, despite experiencing similar pubescent hormonal changes.
The village societies in which these individuals lived also provided an environment that allowed for transition. There is evidence that the condition, documented to span generations (Imperato-McGinley 1979), was not unfamiliar. Local vernacular contains a term for these males, guevedoche, or ¿½penis at twelve¿½ (Herdt 1990). This term suggests that the villagers were aware of not only the condition, but also the physical changes that seemed to blur gender confirmation. Although not noted by the authors of the study, this awareness and terminology seems to reflect an ideology that does not adhere to sexual dimorphism, using instead three categories to reference gender (Herdt 1990). There is not only male and female, but also guevedoche. Herdt¿½s examination of the narratives also indicates evidence that despite the claim that 18 subjects were raised ¿½unambiguously¿½ as girls, the villagers would have had sufficient knowledge of the condition to recognize the possibility for these individuals to undergo pubescent changes, for instance, several of the subjects were closely related to one another and functioned within the same family group (Herdt 1990). Therefore, they were assigned conceptually as guevedoche, not female. This is reinforced by another term adopted by the villagers to describe the males, machihembre, or ¿½first woman, then man¿½. (Herdt 1990) The dialect suggests a social construction of biological sex which allows for transition, sex classifications outside the binary, and an adaptation to the intersex individual without medicalizing gender.
Studies among the Sambia of Papua New Guinea also reveal an additional category in gender assignment for intersexuals with steroid 5-alpha reductase deficiency (Herdt 1990). The Sambia possessed an awareness and detailed knowledge of this syndrome, although this was more clearly documented than in the Dominican Republic. The most common term used for the intersex individual is kwolu-aatmwol, meaning ¿½female thing-transforming-into-male thing¿½ (Herdt 1990). As in the Dominican Republic, this terminology reflects a more fluid conception of gender and sex that is not static or binary. Even though the term draws an inherent comparison between male and female gender to define the intersex individual, the kwolu-aatmwol are not considered singularly male or female (Herdt 1990). According to Herdt, infants are ¿½carefully¿½ examined to determine sex assignment, only kwolu-aatmwol who are mistaken for normative females are assigned and reared as girls; when the condition is recognized the infant is assigned kwolu-aatmwol and ¿½reared in the direction of masculinity, but not ambiguously¿½ (1990). This observation communicates a cultural adaptation to intersexuality by the Sambia. The individuals were not raised exclusively masculine or feminine when ambiguity was determined, developing instead within a unique gender category.
The magnified ethnographic scope used in Papua New Guinea provides a closer insight into some of the particulars of the social response of the Sambia to intersexuality, as well as an interpretation of gender transition motives that focuses on social and cultural forces as opposed to the role of biology in identity development. Of the fourteen intersex subjects identified by Herdt, five were mistakenly assigned female and reared, sometimes ¿½ambiguously¿½, as girls (1990). One of the subjects lives as a female, although is considered a kwolu-aatmwol and is unmarried, the remaining four transitioned in varying degree toward a masculine gender role (Herdt 1990). However, in contrast to the guevedoche, the transitions came only after social forces exposed their biological differences. For example, one of the subjects was forced to move to a faraway town after she entered a marriage and was discovered to have a small penis. Relative prevented the furious husband from killing her, and she fled. It was then that he began using a masculine name, dressing in men¿½s clothes, and dating women, although Herdt notes that ¿½he seems uninterested in them¿½ (1990). It would seem that in the case of the Sambia, it was rather society¿½s dissatisfaction with the ¿½female-assigned hermaphrodite¿½s body¿½ and her ability ¿½to sexually and reproductively deliver what was necessary for her to fulfill her social destiny¿½ that brought on gender role change, not biological masculinization (Herdt 1990).
The incongruity between gender role and social expectation may be considered more problematic than intersexuality for the Sambia, whose culture provides a category other than male or female in language and social expectation. Within the Sambia, kwolu-aatmwol are typically regarded with pity, but included in ¿½normative¿½ society, and may even ¿½rise to distinction through special achievements¿½ (Herdt 1990). While the assignment comes with significant social stigma (it is a belief among the men that women may kill an intersex infant), many kwolu-aatmwol are known locally for being shamans or war leaders (Herdt 1990). The mythology of the Sambia contains a narrative with a ¿½hermaphroditic theme¿½ that tells the story of ¿½two persons, with small breasts and tiny penes, who began the world¿½ (Herdt 1990). These cultural aspects form a special societal, ¿½sacred¿½ role (Herdt 1990) for the intersex of the Sambia, instead of imposing the expectations to accommodate a sexual binary.
The studies of intersex individuals in the Dominican Republic and Papua, New Guinea present some significant contradictions to in regards to how gender is typically conceptualized by the Western medical community. From a social perspective, it would appear that the rural villages of the Dominican Republic and the Sambia have fostered and maintained a ¿½three-category sex code¿½ in response to the existence of intersex individuals over generations (Herdt 1990). In contrast, the Western medicalization of gender (resulting from reductionist perspectives of sex) has caused the intersex to be viewed as abnormal and ambiguous, requiring clinical treatment to satisfy the conditions of either the male or female sex. Intersexuality is considered incomplete or inconsistent male- or femaleness, which has influenced life-changing and often irreversible clinical ¿½corrections¿½ that, in the case of intersex infants, is done without patient consent. While these procedures are generally recommended in the interests of the infant, they also serve the interests of a sexually dimorphic society that frames healthy sex and gender development within a restrictive binary. Cultural examples from Papua New Guinea and the Dominican Republic contradict the assumed universalism of Western sexual dimorphism, and offer a clearer interpretation of the social forces that direct the treatment of the intersex.
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