The Tyranny of the Esthetic
Sexual conformity at the point of a knife is being forced on women whose genitals are declared not "normal" -- with devastating results
Martha Coventry as a child, with her father (far left), and today.
Big clitorises aren't allowed in America. By big, I mean over three-eighths of an inch for newborns, about the size of a pencil eraser. Tiny penises, under one inch, aren't allowed either. A big clitoris is considered too capable of becoming alarmingly erect, and a tiny penis not quite capable enough. Such genitals are confounding to the strictly maintained and comforting social order in America today, which has everyone believing that bodies come in only two ways: perfectly female and perfectly male. But genitals are surprisingly ambiguous. One out of every 2,000 babies is born with genitals that don't elicit the automatic "It's a girl!" or "It's a boy!" Many more have genitals that are perceived as "masculinized" or "feminized," although the child's sex is not in doubt.
The American Academy of Pediatrics recommends surgically altering these children between the ages of six weeks and 15 months to fashion their bodies into something closer to perfection. Everyone can then breathe easier, except for the child, who may well spend the rest of her or his life trying to let the breath flow easy and full through the fear and shame created by such devastating surgery.
On a November night in 1958, I was playing in the bathtub in the cheery, country home of my childhood. I was six years old. My mother came in and sat on the edge of the tub, her kind face looking worried. I glanced up at her, wondering, "Time to get out so soon?" She told me that I had to go to the hospital the next day for an operation. I knew this was about something between my legs. My chest felt tight and there was a rushing sound in my ears. I begged not to go. Please. But my mother told me only that I must. Not a word was said about what was going to happen or why. The next day, it took the surgeon 30 minutes to make a U-shaped incision around my half-inch clitoris, remove it, and put it in a specimen dish to send to the lab. He then closed the wound and stitched the skin up over the stump.
Take no comfort in the fact that this took place 40 years ago. Today, most parents and doctors in this country are still unable to see that a child has a right to her or his own sexual body, even if that body is deemed "abnormal" by their standards. If a parent is uncomfortable, a doctor can be found who will be willing to make irreversible changes in the child's body, in order to ease that discomfort. My gynecologist told me about a case in which he had been involved the year before: A woman brought her five-year-old daughter to his office in Minneapolis; the mother felt that the child's clitoris was too big. He examined the girl and assured the mother that her daughter would grow into her clitoris, which was no longer than the end of his little finger. The mother left. A few weeks later, he was called into an operating room to help another doctor who had run into trouble during a surgical procedure. On the table, he found the same little girl he had seen earlier. She was hemorrhaging from a clitorectomy attempted by the second doctor, from instructions he had read in a medical text. My physician stopped the bleeding, and managed to keep the girl's clitoris mostly intact.
It is not new in our culture to remove or alter the clitoris. Not so long ago, such surgery was commonly practiced to prevent masturbation and "unnatural sexual appetites." Although such justifications still lurk in the minds of parents and doctors ("Won't she become a lesbian?" is a concern of many mothers whose daughters have big clitorises), clitorectomies gained new status toward the end of the 1950s, as a "legitimate" way to make a child with atypical genitals feel and appear more normal. Surgical techniques learned during World War II led to advances in the field of cosmetic genital surgery; at about the same time, a new medical discipline -- endocrinology, the study of the hormonal system -- was established at Johns Hopkins University Medical School. A child's body could now be successfully altered by surgery and hormones to look just about any way you wanted it to look. And the controversial research into sex and gender roles by Johns Hopkins' John Money, Ph.D., led doctors to believe that by changing that body, you could make the child into a "normal" male or female, both physically and psychologically. Children could be made "right" if they were born "wrong." And American medicine, and our society at large, sees "imperfect" genitals as wrong.
That view is challenged by farsighted pediatric urologist Justine Schober, M.D., of Erie, Penn.: "Why should we say that, because this is a variation, that it is a wrong variation? If all their faculties work, their sexual sensitivities work, why should we presume that their body is wrong?" But by seeing a child's body as wrong and by labeling such a child "intersexed," we turn a simple variation on a theme into a problem that can and should be fixed. And fixed it usually is, by surgery that sacrifices healthy erotic tissue for cosmetic reasons some five times a day in the U.S. The rules of the game are still the same as they were 40 years ago: Erase any sign of difference, tidy things up, and don't say another word.
After I had my clitorectomy, my innocent life became filled with fear and guilt. The secrecy surrounding my surgery began to undermine my entire sense of identity. I knew I had had something between my legs cut off, and I could imagine only that it was a penis. Girls were Barbie-doll smooth, so there wasn't anything on a girl to cut off. Was I really a boy? Or perhaps the horrible thing I had somehow known about forever: hermaphrodite? The study of my father, a physician, was full of medical books, but I flipped through them quickly, drawn to the pictures of children with their eyes blacked out, knowing there was something we shared, yet terrified to find out what kind of freak I really was. Then, one night when I was 11 or 12, I found my parents, as they sat at the dining room table, looking at studio pictures of my sisters and me. My mother held up my photo and I heard her say the word "boy." My gut heaved. I was a boy. It was true. I blurted out, "What was that operation I had?" My father turned to me and said, "Don't be so self-examining." I never had the heart to tell this man who loved me so dearly that, by keeping the truth from me that night, by trying to protect me from my own wondering mind and wandering hands, he had sentenced me to a life of almost crippling fear in relation to my sexuality, even to a profound doubt of my right to be alive.
It would be 25 years before I could begin to start asking questions again. When I finally pressed my dying father as gently as I could for a reason why he and my mother wanted my clitoris removed, he said, "We didn't want you to be mistaken for a hermaphrodite." My father was a surgeon. No doctor had patronizingly spun to him tales of "improperly formed gonads," or lied to him about my medical condition, or told him I would become a lesbian if I had a big clitoris, or pretended that no other children like me existed. Just having a child with an abnormal body in Rochester, Minn., was bad enough for my parents. But doctors do lie -- to parents and to children, in a gross insult to their intelligence and their right to the truth. Lying to children is a rule strictly adhered to, and enforced, by all but the most enlightened doctors. First the surgery steals your body from you, then lies confirm that there is so little respect for you as a human being that you don't even deserve the truth.
X Marks the . . .
Angela Moreno was a happy child growing up in the late seventies in Peoria, Ill. She was fairly sexually precocious with herself, and became very familiar with her clitoris: "I loved it, but had no name for it. I remember being amazed that there was a part of my body that was so intensely pleasurable. It felt wonderful under my hand. There was no fantasy, just pleasure -- just me and my body." Life in the pleasure garden came to an abrupt end for Angela when, at age 12, her mother noticed her protruding clitoris while Angela was toweling off after a bath. After being examined by her family doctor, she was sent to an endocrinologist. The endocrinologist revealed to her parents that, instead of the two X chromosomes that characterize the female genotype, Angela had an X and a Y. She was "genetically male." She had the external genitalia of a female because the receptors for the "male" hormone testosterone did not function; that is, her body was unable to respond to the androgenizing or masculinizing hormones it produced. Her parents were assured that if surgeons removed Angela's internal testes, and shortened her clitoris, she would be a "very normal little girl," albeit one born without ovaries or a uterus. This was lie number one.
Just because your body may look "normal" is no guarantee that you will feel that way. The truth is that the very thing surgery claims to save us from -- a sense of differentness and abnormality -- it quite unequivocally creates.
Doctors then told Angela's parents that if she didn't have surgery she might kill herself when she found out that she was different from other girls. It had happened to another patient, the physicians said, and it could happen to Angela. Although such speculation is not a lie, it is also not the whole truth. In my talks with scores of people with atypical genitals, it is those who have been surgically altered as children and left alone with their trauma who most often become suicidal. The isolation from others who have experienced what we are going through, the loneliness, is what kills us. Angela's parents were justifiably frightened and agreed to the surgery.
The final lie was to Angela herself, with her distraught parents' complicity. She was told, at her physicians' suggestion, that her nonexistent ovaries could become cancerous and that she would have to go into the hospital and have them removed.
In 1985, at a leading children's hospital in Chicago, doctors removed the testes from Angela's abdomen. The clitoris that had brought her so much joy was not merely shortened, it was all but destroyed. She woke up and discovered the extent of the deceit: "I put my hand down there and felt something like the crusty top of some horrible casserole, like dried caked blood where my clitoris was. I wondered why no one told me and I just figured it was the kind of thing decent people don't talk about."
Angela became depressed and severely bulimic. "I blamed my body. My body had betrayed me. Made me someone worthy of that kind of treatment. I just studied and puked." She was a straight-A student in high school, but otherwise, her adolescence was a nightmare. She avoided becoming close to other girls her age, afraid she would be asked questions about the menstrual period she knew she would never have. The uncomplicated sexuality she had reveled in before the clitorectomy was gone, and she was desolated by the loss of erotic sensation. In an attempt to find out the truth, she returned to her original endocrinologist, who told her that her gonads had not formed properly, and her clitoris had grown because of an abnormal level of hormones. She did not tell Angela about her XY status or her testes. Angela fell deeper into darkness, sensing that she had not been given the whole story. Finally, at 20, weakened by chronic and near-lethal bingeing and purging, and suicidal, she checked herself into a psychiatric unit.
After her release, she began seeing a therapist who finally hit on the connection between her bulimia and the control she lost over her body at the time of surgery. Angela knew she had to find out the mystery of her body in order to get well. By now she was 23 and could legally obtain her medical records, yet it took a year for her to find the courage to write for them. When she received them and read the truth about herself, she could begin at last to save her own life. "Although the doctors had claimed that knowing the truth would make me self-destructive, it was not knowing what had been done to me -- and why -- that made me want to die."
In my case, I have XX chromosomes, and my outsized clitoris was the only part of my body that was not like that of most other girls.
Do these facts make you want to differentiate me from Angela? To say, "Wait a minute. You were simply a girl born with a big clitoris, but Angela had a real pathological condition." But the doctors removed Angela's clitoris for exactly the same reason they removed mine -- they thought it offensively large. Her chromosomes and her abdominal testes had no bearing on the decision.
If you rush to see Angela as fundamentally different from me, if you see her as a real intersexual and me as just a normal woman, you do two very damaging things: You may see it as justified to perform cosmetic surgery on her and not on me because she really is "abnormal," and you separate us from each other and deny our right to find solace and strength in the sameness of our experience.
The doctor who was kind enough to help me begin to explore my early surgery did just that to me. I found the Intersex Society of North America on my own several months after my initial visit with him, and told him later how healing it had been to find others who knew intimately what my life had been like. He had known about ISNA all along, he said, but didn't pass the information on to me because I was not intersexed. I was a real woman. He had tried to save me from a pathologizing label, but ended up enforcing my isolation instead.
New and Improved?
When a baby is born today with genitals that are ambiguous, a team of surgeons, pediatric endocrinologists, and social workers scramble to relieve what is called a "psychosocial emergency." Tests are done and orifices explored to determine as nearly as possible the baby's "true sex." Then, in almost all cases, doctors perform surgery to make the child look more like a girl, because, they say, the surgery required is easier to perform than trying to make the child look like a boy.
The form this feminizing surgery most often takes is the dissection and removal of healthy clitoral tissue -- a clitorectomy, also known as "clitoral recession," "clitoral reduction," and "clitoroplasty." Sensitive, erectile tissue is stripped from the shaft of the clitoris, and the glans is tucked away so expertly that all you see is the cute little love button that is the idealized clitoris. But the pleasure is almost gone, or gone completely, for the owner of that dainty new clit. If orgasms are possible, and they aren't for many women subjected to clitoral surgery, the intensity is greatly diminished. One woman whose clitoris was "recessed" writes: "If orgasms before the recession were a deep purple, now they are a pale, watery pink."
Doctors maintain that modern surgery retains more clitoral sensation than the older forms of surgery, but they base their assurance on nerve impulses measured by machines -- supposedly accurate and unbiased information -- and not the real experience of thousands and thousands of women in this country. This is because no long-term post-surgical studies have been done. I, who had the old-style surgery, have clitoral sensation and orgasmic function, while those subjected to more modern surgeries often have neither. How much do doctors truly care about a child's sexual future if they decimate the one organ in the body designed solely for pleasure?
In 1965, Annie Green, then three years old, took a car trip with her father from the small town in Idaho where she lived to Spokane, Wash. She sat in the back seat with her stuffed animal, unaware that she was on her way to the hospital. The next day doctors removed her inch-long clitoris. She was never given any explanation of her surgery. As she got older, her attempts to find pleasure in masturbation failed, and she began to suspect that she was very different from other girls. Then, during a visit to her sister's house as a teenager, she found the book Our Bodies, Ourselves: "I studied the female anatomy and read about sex from that book. That was when I learned I didn't have a clitoris. I remember looking at the diagram, feeling myself, and reading what a clitoris was over and over. My God, I couldn't figure out why I didn't have one. I couldn't fathom anyone removing it if it was that important. I was stunned, and I held it all in. I was only 14. I became depressed. I was disgusted with my body, and I thought there was no hope that I would ever be loved by anyone. I became a little teenage alcoholic. I drank heavily every weekend. I really blew it because I had been a really good athlete and an honor student."
Clitoral surgery on children is brutal and illogical, and no matter what name you give it, it is a mutilation. When I use the word mutilation, I can hear doors slamming shut in the minds of doctors all over this country. John Gearhart, a pediatric urologist at Johns Hopkins, has said, "To compare genital mutilation of young girls in Africa to reconstructive surgery of a young baby is a giant, giant leap of misrepresentation." But neither Dr. Gearhart, nor anyone else, has ever bothered to ask those of us subjected to clitoral surgery as children if being taken to the hospital without explanation, having your healthy genitals cut and scarred, then left alone with the results feels like mutilation or "reconstructive surgery." Gearhart's mistake is to judge surgery only by the surgeon's intent, and not by the effect on the child. I spoke with a woman recently who is young enough to be my daughter. With great effort, she told me of her clitoral surgery as a child. She implored me, "Why do they have to cut so deep, Martha? Why do they do that?"
Of the notable feminist voices raised long and loud in outrage over traditional genital surgeries practiced in parts of Africa, which are now denounced as "female genital mutilation" (FGM), not a single woman has said a word about the equally mutilating practice of surgically destroying the healthy genitals of children in their own country. Like Gearhart, they shrink when we describe our surgeries as mutilation. But do they believe that African mothers, any more than American surgeons, cut their children out of malicious intent? Could their silence be because they don't know what is happening in American hospitals? It's possible, but this issue has received media coverage in the past year, and many of them have had the facts explained to them in person or in writing.
I could speculate that these women don't want to take on a foe as formidable and familiar as the medical profession, and that it is simpler to point fingers at more barbaric countries. They may not want to dilute their cause with the sticky subjects of sex and gender that surround the issue of ambiguous genitalia. Or perhaps they don't want to be aligned with children they can only see as freaks of nature. Even the liberal-thinking Joycelyn Elders, the former Surgeon General, refers to children who blur gender lines in a less-than-humane way. When Elders, a professor of pediatric endocrinology who continues to promote "reconstructive" surgery for girls with big clitorises, was asked about the wisdom of genital surgery on such children, she responded with, "Well you just can't have an it!"
Each woman has her own reasons for turning away from this issue. But I challenge them to pay attention to the fact that in hospitals just down the street in any big American city, five children a day are losing healthy, erotic parts of their bodies to satisfy a social demand for "normalcy." There is no Federal ban to save them. The surgery is left out of the law against FGM because it is deemed "necessary to the health of the child on whom it is performed." But as social psychologist Suzanne Kessler at the State University of New York at Purchase points out, "Genital ambiguity is corrected not because it is threatening to the infant's life, but because it is threatening to the infant's culture."
Doctors and parents believe society will reject a child with atypical genitals, and the child is made to pay with her or his body for this shortcoming of our culture. What is happening in American hospitals to healthy children is just as mutilating to the bodies -- no matter how exquisite the surgical craftsmanship -- and violating to the souls of these children as FGM. And frequently, the surgical craftsmanship falls far short of exquisite.
The strict sexual agenda for bodies in America extends to little boys as well. To grow up to be a real man, a boy will have to be able to do two things -- pee standing up and penetrate a vagina with his penis. If a little boy has to sit like a girl to urinate because his urethra exits somewhere along the shaft of his penis rather than the tip (a condition that can occur in as many as 8 out of 1,000), he may be subjected to many disheartening surgeries over the course of his childhood to correct this "defect," and be left with a lifetime of chronic infections and emotional trauma. And if the baby is born with a "too-small" penis that doctors decide will never be big enough to "successfully" penetrate a woman, physicians will probably make him into a "girl" through surgery and hormone treatments, because, in the words of one surgeon, "It's easier to poke a hole than to build a pole."
In the 40 years since surgical intervention to "correct" genitals that are viewed as abnormal was first prescribed, treatment protocols have rarely been questioned. After all, it is much more comfortable for doctors to assume all is well than to start digging around to find out if it's really true. Until recently, all discussions of what is done to people's sexual bodies have been hidden safely away in the pages of medical texts, where real lives are only "interesting cases," and pictures of genitals are disembodied curiosities or teaching tools. Many doctors would like to keep things that way. For example. Dr. Kenneth Glassberg, a pediatric urologist associated with the American Academy of Pediatrics (AAP), insists that people who speak up and tell their stories are doing a disservice by "scaring patients away."
In a blatant disregard for patient feedback not seen in any other medical field, the AAP still advocates early surgery and insists that the "management" of children with atypical genitals has improved over the past several decades. Their refusal to consider the reality of the lives of people who have been treated by this protocol can be likened to an astronomer gazing at Mars through his telescope while ignoring the real live Martian tugging at his sleeve. The messy truth of what happens to children treated with surgery and hormones is simply ignored by the AAP, as they stubbornly cling to a treatment paradigm that has never been anything but experimental.
Cosmetic genital surgery on children is out of control. As the practice has careened along unexamined for decades, illustrious careers and reputations have been made, consciences have been swallowed, and terrific damage has been done. For a doctor even to hesitate before operating takes tremendous effort and self-reflection. The need for babies to have genitals that look typical has been perceived as so unquestionable that surgeons travel all over the world to perform surgery on children free of charge as a "humanitarian gesture."
Dr. Justine Schober challenges her fellow surgeons to realize that "when you do [this kind of] surgery on someone, you are responsible for them for the rest of their lives." In less than two hours in a sterile operating room, a child's personal and sexual destiny can be changed forever. The stakes are excruciatingly high for the sake of appearances. Angela's story, Annie's story, and my own tell only the smallest fraction of the terrible fallout from these surgeries. No one is naive enough to say that a life in a body seen as abnormal is a ticket to bliss. But it is not the bodies of these children that are wrong, it is the way people see them. And if these children grow up and want to change their bodies one day, that will be their right. Nobody, but nobody, no matter how loving, no matter how well-intentioned, should have the power to steal precious parts of a body from a child before she or he even gets started in life.
Martha Coventry is currently writing a book about childhood genital surgery in America. She lives and works in Minneapolis.