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Unformatted text preview: weight to testes—not trivial (think
of a 175-pound man with nearly two pounds’ worth of testicles), but
nowhere near what the type II males do.25
The two types of males also secrete two different types of testosterone, and only type I males make and guard nests. Inside the warmth
of those nests, these guys hum Johnny Mathis tunes with their husky
voices and wait for females to come to them. Type II males don’t sing
and don’t build or guard nests. Instead, these Lotharios prefer to slip
into a type I male’s nest and mate with the resident female while hubby
is away. Just what evolutionary advantage this offers to midshipman fish
isn’t clear. But among the saddleback wrasse and the midshipman fish,
three very different sexes persist.
No matter how hard we may try to squeeze these fish tales into
our human stories, sex remains—as pioneering geneticist J. B. S. Haldane said of all the universe—“not only queerer than we suppose, but
queerer than we can suppose.” 6
What We Do About the
Dozens of species of fish do it. Even female spotted hyenas with penises
do it. All of these creatures mix in more than two sexes, move from
female to male and in between as easily and quickly as we change
clothes, and that doesn’t seem to bother any of us. We don’t feel that
we ought to do something about these animals. But when it comes to
human beings, everything changes. We have social norms, expectations,
and high school showers to deal with. And of course we have the vise of
language with its steel pincers. When it comes to human intersex, many
people find themselves in a curious and frightening void. The only way
out of that void is through the child.
Limiting the Ambiguity: Assigning a Gender
In the summer of 2006, the Lawson Wilkins Pediatric Endocrine Society
and the European Society for Paediatric Endocrinology gathered together
“fifty international experts in the field” to answer some of the questions
that surround the birth of an intersex child. Their report appeared in
2007 as the “Consensus Statement on Management of Intersex Disorders.” This group was not the first, and I’m certain it won’t be the last, to
tackle the thorny issues of sex and gender assignment, the welfare of the 115 116 Between XX and XY children and their parents, what sort of expertise should be available, and
how physicians can best serve all of those involved. It isn’t entirely clear
why this task should fall to physicians, but I think their conclusions offer
a useful insight into some of our current thinking about intersex.
First, this group recommended that we change the words we use
to describe intersex people. “Terminology such as ‘pseudohermaphroditism’ is controversial, potentially pejorative to patients, and inherently confusing.” They proposed in its place the term “disorders of sex
development” or DSDs “to indicate congenital conditions with atypical
development of chromosomal, gonadal, or anatomic sex.” That seems
a reasonable conclusion. After all, very few of us, even without years
of medical training, feel that the term hermaphrodite adds to our social
currency. And this conclusion acknowledges, up front, the crucial role
played by language in this whole area. The language we use to describe
ourselves and the words that others use to name us change the way we
see everything. Words are not innocent bystanders here.
Then it was time to address the hard clinical issues, gender and sex
assignment, surgeries, expertise, parents, and children.
“Standards of care for best clinical management of DSD include a
gender assignment for all; avoiding gender assignment before expert
evaluation in newborns; open communication; multidisciplinary-team
evaluation and management; family/patient participation in decisionmaking, respect and attention to patient/family concerns; and strict
“A gender assignment for all.” What that really means is everyone,
and we mean everyone, has to be either a boy or a girl. If we have
done away with hermaphrodites and pseudohermaphrodites, what else
is there? And those involved must choose between these two options
just as soon as the team and the parents can agree on what’s best for
this child, the consensus being that no one in our society can wander
around productively and sanely without an attached indication of sex.
And who should make those decisions and should assist?
“The core team should consist of pediatric endocrinologists, surgeons, urologists, or gynecologists, psychologists/psychiatrists, geneticists, neonatologists, social workers, nurses, and medical ethicists.” What We Do About the Ambiguous Child 117 “DSD should be suspected 1) in cases with overt genital ambiguity
(such as cloacal exstrophy [a DSD where no genitalia develop and the
lower abdomen fails to close], 2) if the genitalia are apparently female
but include an enlarged clitoris [This particular study doesn’t say exactly
when a clitoris should be considered enlarged. However, it does provide
very specific information about penis sizes in Japan, India, Aus...
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- Spring '14