Many Christians, entrenched in culture wars over sexual ethics, are either ignorant of the existence of intersex persons or avoid the inherent challenge they bring to the assumption that everybody is born after the pattern of either Adam or Eve. DeFranza argues, from a conservative theological standpoint, that all people are made in the image of God -- male, female, and intersex -- and that we must listen to and learn from the voices of the intersexed among us.
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Sex Difference in Christian Theology
Male, Female, and Intersex in the Image of God
By Megan K. DeFranza
William B. Eerdmans Publishing CompanyCopyright © 2015 Megan K. DeFranza
All rights reserved.
Intersex: Medical and Sociological Challenges to the Two-Sex Model
I begin this chapter by exploring contemporary medical descriptions of intersex. I will trace the history of intersex from the time before medical technology — when intersex existed at the margins of society — to the virtual erasure of intersex by the medical establishment. We will then hear objections to the medicalization of intersex, paying particular attention to the voices of intersex persons themselves. Lastly, we will hear from those who lay the blame for the abuse of the intersexed at the feet of the two-sex model and ask whether Christianity is to blame for the binary.
What Is Intersex?
Typical Sex Development
"Intersex" is a term used to describe persons who do not fit into standard medical descriptions of male or female. It is important at the outset to establish what is considered normal or typical by the medical community so that variations from the norm can be understood. In this book "normal" is employed according to the classical sense of "norm," "standard," or "type." Thus, "abnormal" does not indicate "freakishness" but atypical development.
Brown University biologist Anne Fausto-Sterling describes what is considered "typical" or "normal" by medical practitioners today:
We define the typical male as someone with an XY chromosomal composition, and testes located within the scrotal sac. The testes produce sperm which, via the vas deferens, may be transported to the urethra and ejaculated outside the body. Penis length at birth ranges from 2.5 to 4.5 cm; an idealized penis has a completely enclosed urethra which opens at the tip of the glans. During fetal development, the testes produce the Mullerian inhibiting factor, testosterone, and dihydrotestosterone, which juvenile testicular activity ensures a masculinizing puberty. The typical female has two X chromosomes, functional ovaries which ensure a feminizing puberty, oviducts connecting to a uterus, cervix and vaginal canal, inner and outer vaginal lips, and a clitoris, which at birth ranges in size from 0.20 to 0.85 cm.
Intersex as an Umbrella Concept
The term "intersex" is not a diagnosis but an umbrella concept used to cover a wide range of variations in sex development. Many intersex conditions result in ambiguous genitalia, either at birth or throughout the life course of the individual; however, not all intersex conditions are indicated by genital inspection. The Consortium on the Management of Disorders of Sex Development lists the following as intersex-related conditions: "congenital development of ambiguous genitalia, congenital disjunction of internal and external sex anatomy, incomplete development of sex anatomy, sex chromosome anomalies and disorders of gonadal development." Each of these will be described in what follows.
"Intersex is not a discrete or natural category." While most people believe they know what makes a person male or female — chromosomes, gonads, genitals, secondary sex characteristics — it is not clear what type and how many variations to these norms it takes to classify a person as intersex. Should a person with external female genitalia who has XY chromosomes and testes be considered male, female, or intersex? How large does a clitoris need to be before it is considered a micropenis? These decisions are made by humans, typically by doctors. What doctors believe about physical norms and variations, the usefulness of the intersex designation, and gender value all factor into decisions about sex assignment. These beliefs also contribute to debates over which conditions "count" for estimates of frequency rates.
It will be helpful for the reader to become familiar with certain intersex conditions before entering the debate over which variations "count." An exhaustive list of intersex conditions is not possible or necessary here. Instead, I will describe some of the more common variations and their implications for what follows.
Types of Intersex Conditions
Androgen Insensitivity Syndrome (AIS) AIS is an intersex condition that occurs roughly once in every 13,000 births. Androgen insensitivity comes in two types: complete (CAIS) and partial (PAIS). Persons with AIS are born with XY chromosomes (i.e., as in a typical male). XY chromosomes set into motion the normal development of testes, which begin to secrete higher levels of testosterone in XY individuals as early as the eighth week of gestation. But people with AIS are unable to process male hormones (androgens). Because their cells lack the proper receptors, persons with CAIS develop female external genitals. They retain undescended or partially descended testes. They usually have a short vagina and no cervix, though some lack a vagina altogether. Because genitals appear normal (for females) at birth, CAIS is not usually discovered until puberty when menstruation does not occur.
Given this description of androgen insensitivity, the reader may not find it surprising that these "girls" do not menstruate. What is surprising, however, is that these individuals do develop secondary sex characteristics typical of pubescent females. The Intersex Society of North America (ISNA) explains how feminizing puberty is possible. "At puberty, the testes are stimulated by the pituitary gland, and produce testosterone. Because testosterone is chemically very similar to estrogen, some of the testosterone converts back to estrogen ('aromatizes') in the bloodstream. This estrogen produces breast growth, though it may be late." Thus, higher levels of testosterone during puberty result not in the typical masculinization of those with androgen receptivity (i.e., growth of underarm and pubic hair, Adam's apple, voice descent, increased muscle mass); rather, higher levels of testosterone have the opposite effect — increased feminization of XY individuals. CAIS has been called "classical testicular feminization" in recognition of this process. It has also been labeled "male pseudohermaphroditism."
The designation "male pseudohermaphroditism" gained parlance in the Victorian era. During the nineteenth century, doctors looked to gonads to determine sex assignment when genitals were "unclear" or, in CAIS individuals, when normal sex development — such as menstruation — did not occur. Gonads were seen as primary for two reasons. First, reproduction was viewed as the principal marker for sex identification. Second, scientific knowledge of gonadal hormone production and gonadal influence on sex development was growing. Within the Victorian schema, the CAIS patient, with male gonads and female genitalia, would be considered a "male" on account of "his" testes, but a "pseudohermaphrodite" on account of "her" genitals and secondary sex traits. On the flip side, a person with male external genitals and ovaries would have been labeled a "female pseudohermaphrodite." The only persons labeled "true hermaphrodites" were those who possessed both an ovary and a testis, a rare condition now called "ovo-testes." More recent scholars reject the term "pseudohermaphrodite" because it is considered offensive, confusing, and imprecise.
While in the Victorian era persons with AIS would have been considered "men" by the medical establishment, today these individuals are overwhelmingly declared to be women. They look like girls at birth. They look like women after puberty. Paradoxically, CAIS women develop along the lines of the contemporary, Western ideal of womanhood: they are tall and lean, with little to no body hair. Additionally, these individuals typically have unquestioned female gender identities and roles until confronted with their diagnosis, either at puberty or as adults.
Partial androgen insensitivity is less common than the complete form, occurring approximately in only 1 in 130,000 births Whereas individuals with CAIS appear "unambiguously" female, persons with partial androgen insensitivity syndrome (PAIS) have bodies that fall anywhere along the spectrum. Charmian Quigley and Frank French, doctors at the Laboratories for Reproductive Biology, University of North Carolina at Chapel Hill, "proposed a grading system for the phenotypic features (external appearance) in AIS. The scale runs from AIS Grade 1 to Grade 7 with increasing severity of androgen resistance — and hence decreasing masculinization with increasing feminization." The following chart and explanatory paragraph may be found at www.AISSG.org, the Web site of one of the largest and most trusted support groups for persons with AIS:
Grade 1 PAIS Male genitals, infertility
Grade 2 PAIS Male genitals but mildly "undermasculinized,"
Grade 3 PAIS Predominantly male genitals but more severely
"undermasculinized" (perineal hypospadias; small
penis; cryptorchidism, i.e., undescended testes;
and/or bifid scrotum)
Grade 4 PAIS Ambiguous genitals, severely "undermasculinized"
(phallic structure that is indeterminate between a penis and a clitoris)
Grade 5 PAIS Essentially female genitals (including separate urethral
and vaginal orifices; mild clitoromegaly, i.e.,
Grade 6 PAIS Female genitals with pubic/underarm hair
Grade 7 CAIS Female genitals with little or no pubic/underarm hair
At the CAIS end of the spectrum the outward appearance is completely female (AIS grades 6/7) and the sex of rearing is invariably female. In PAIS the outward genital appearance can lie anywhere from being almost completely female (grade 5), through mixed male/female, to completely male (grade 1); it has been suggested that slight androgen insensitivity might contribute to infertility in some otherwise normal men. Some babies with PAIS may be raised as males but many are re-assigned as female.... Before puberty, individuals with Grade 6 or 7 are indistinguishable.
Some individuals with complete androgen insensitivity reject the label intersex. They consider themselves females and resent association with those whose sex or gender identities are less certain. On the other hand, individuals with partial androgen insensitivity, especially those resulting in ambiguous genitals, are more likely to resonate with intersex terminology and the efforts of intersex advocacy groups. Despite recent efforts by some AIS support groups to distance themselves from intersex concerns, the question of intersex remains. What should determine sex assignment: external genitalia or internal gonads, reproductive structures or personal gender identity?
The shifting opinion of the medical community over the years illustrates how scientific categories as basic as sex difference are nevertheless subject to social construction. When society (e.g., the medical establishment) considers gonads or chromosomes as the primary markers of sex, persons with CAIS are identified as "really" men. When the medical or psychological establishment considers external genitalia and personal gender identity as primary, persons with CAIS are labeled as "really" women.
Given the reality of social construction for sex among the intersexed, it is valid to question the entire schema within which such construction currently takes place. Should persons with CAIS or PAIS be forced to choose between two options for sex assignment? Should they be given a third option, intersex, along with the traditional categories, male and female? Some have proposed an even more nuanced scheme, wherein one would combine labels. Thus, a person with CAIS who identifies as a woman would be considered an "intersex woman." Such a designation recognizes that XY individuals with CAIS can appear more feminine than XX women and more accurately reflects the complexity of the issues for sex and gender identification.
Fausto-Sterling once suggested public recognition of the five sex categories used by medical doctors since the Victorian period: male, female, male pseudohermaphrodite, female pseudohermaphrodite, and true hermaphrodite. Sociologists Suzanne Kessler and Wendy McKenna argue that the entire system should be tossed. If people want to identify as a particular sex, or as intersex, let them. Some may want to identify as male or female during their reproductive years, so as to find a suitable partner, and then change designation at other (nonreproductive) seasons of life. They ask: What's the harm? We will return to their proposals toward the end of this chapter, but now we turn to one condition formerly known as "female pseudohermaphroditism."
Congenital Adrenal Hyperplasia (CAH) CAH is an intersex condition that occurs anywhere between 1 in 13,000 and 1 in 36,000 births. It is an "inherited enzyme deficiency condition, causing a malfunction of the fetus's adrenal gland, which results in the overproduction of fetal androgen." Thus XX individuals can have androgen levels that are similar to those of typical males, and XY individuals can have higher than average levels. Higher levels of androgens "can make XX embryos have larger than average clitorises, or even a clitoris that looks rather like a penis, or labia that look like a scrotum."
"Virilization in girls with CAH is highly variable," Melissa Hines writes. At the same time, "in a small number of cases, virilization is so extensive that genetic females are misidentified as males at birth and assigned and reared as boys until other consequences of the CAH syndrome result in a correct diagnosis. Usually, this occurs sufficiently early to allow reassignment to the female sex. However, in some cases it does not. XX individuals with CAH do not have testes or Mullerian Inhibiting Factor, and so they retain female internal reproductive organs and are capable of reproducing. Virilization does not stop after the birth of the child. CAH can trigger other secondary sex characteristics typical of male puberty: "dense body hair, a receding hairline, deep voice, prominent muscles, etc."
In 1954 Andrea Prader created what has come to be called the Prader Scale to classify degrees of virilization caused by CAH:
Normal Female normal female genitals
I slight enlargement of the clitoris (cliteromegaly)
II enlarged clitoris and partial fusion of the labia
producing a "funnel-shaped" cavity for the urethra
and vaginal openings
III enlargement of the clitoris such that it is often
described as a "phallus." At this stage the labia
are so fused that they are indistinguishable from a
scrotum, and there is only one "urogenital" opening
IV complete fusion of the scrotum with urogenital
opening at the base or shaft of the "phallus," what
is often labeled hypospadias on a genetic male
V mild to medium hypospadias
"Among the many causes of intersex, only CAH represents a real medical emergency in the newborn period." CAH can cause severe dehydration leading to death within the first weeks of the infant's life. At puberty, additional medical intervention is needed to create a vaginal opening separate from the urethra for menstruation and so that urine does not pool in an internalized vagina.
CAH can also occur in XY males, who may be in need of medical care and counseling. "[U]ntreated CAH can cause boys to have their puberty earlier than other boys. This can be a problem because it will stop them from growing taller ... and because it can cause them to be very sexual well before other children their age are having such strong sexual thoughts and desires."
CAH is considered an intersex condition only when it occurs in XX individuals. The Intersex Society of North America notes that while "1 in 10,000 to 18,000 children are born with congenital adrenal hyperplasia ... the prevalence of CAH-related intersex is about 1 in 20,000 to 1 in 36,000." But these numbers only represent classic CAH conditions that begin in utero. CAH can also start later in life, something that has been coined late-onset CAH, or LOCAH.
Late-onset congenital adrenal hyperplasia is an enzyme deficiency that occurs anytime after age five. If a child shows premature signs of puberty, clitoral growth, or male pattern hair growth (hirsutism), doctors may check for LOCAH. After puberty, signs of the condition "include hirsutism, menstrual disorders, and clitoral enlargement."
Excerpted from Sex Difference in Christian Theology by Megan K. DeFranza. Copyright © 2015 Megan K. DeFranza. Excerpted by permission of William B. Eerdmans Publishing Company.
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Table of Contents
How I Got Here, xiii,
Another Conversion, xv,
Introduction: Male, Female, and Intersex in the Image of God, 1,
Images of the Image of God, 2,
Intersex and the Current Culture War, 7,
Extant Theological Work on Intersex, 10,
The Intersexed Have Faces, 13,
A Preview, 17,
PART I: MORE THAN TWO: CHALLENGES TO THE BINARY SEX MODEL,
1. Intersex: Medical and Sociological Challenges to the Two-Sex Model, 23,
2. Biblical Resources beyond Adam and Eve: The Case of Eunuchs, 68,
3. How We Got Here: Historical Shifts in Theological Anthropology, 107,
PART II: CRITIQUE AND CONSTRUCTION: THEOLOGICAL ANTHROPOLOGY IN THE POSTMODERN PERIOD,
4. Sex, Gender, and the Image of God: From Other to Others, 153,
5. Sexuality and the Image of God: The Relational Turn, 186,
6. Jesus the True Image: Sex, Gender, and Sexuality in the Postmodern Already/Not Yet, 239,
Index of Subjects and Names, 309,