By Daniel Rodríguez Claveli
In Venezuela, as in many other countries of South America, the fight for the civil rights of the Lesbian, Gay, Bisexual, Transsexual, Transgender, Intersex and Queer (LGBTTIQ) community has resulted in some important laws and cultural changes, although the focus has mainly been on the first five letters of the acronym.
Even though intersexuality is an important part of the above-mentioned community, it doesn’t share the same fate as the other sexual and gender diversities. Intersex people in Venezuela are still marginalized within LGBTTIQ organizations and population in general. Most activists know virtually nothing about intersex people’s personal struggles, and their revindication of human rights.
The present article is the product of research about intersex people and medical protocols in the Hospital Universitario de Caracas (HUC), one of the most important hospitals in Venezuela. The main goals of this investigation were to find out and to show how doctors treat intersex people, what protocol(s) they follow, but most importantly, if there were medical histories being registered at all. I understand intersexuality in this research as the conjugated presence of both genotypic and phenotypic traits of both sexes socially established in the body of a person. Of course, the biggest goals of this research are to criticize intersex diagnosis and practices and the ideology behind it, and to create new public, education and social policies that protect intersex people through shedding light on the experiences and realities of intersex people within the Venezuelan medical institution.
Medical fear or social fear?
The medical control exercised over the body, in this case at the sexual level, arises from a fear. A fear of the disintegration of the sexual male-female binary on which much, if not all, of the Western society is built upon. The mere existence of intersex bodies demonstrates that there are more options on which to build and create different and diverse realities. Therefore, sex categories will no longer be necessarily masculine and feminine, but a spectrum. Since the intersexed bodies create bonds or even bridges within this dichotomy, gray areas appear at a biological level, threatening the social and sexual order.
Venezuelan society has allowed Medicine as an institution (as well as disciplines such as Sexology, Psychiatry and Psychology) to be the main body in charge of creating and endorsing the sexual boundaries of bodies, by defining what should be considered as a female or male body according to medical expertise. However, since people (whether defined as intersex or not) are the ones who live their embodied lives, they should establish our own borders.
During this investigation 15 medical histories of intersex people were found in the HUC archives. All of them were classified under the category: “Q56 Indeterminate sex and pseudohermaphroditism, subcategory: Q56.4 undetermined sex, without other specification (ambiguous genitalia)”.
The collected cases have admission dates between 1999 and 2011, of which nine were attended by the Surgical Pediatrics service and six by the Neonatology service. All cases were diagnosed with undetermined sex, with a wide age range, with ten newborns, three adolescents and two kids. The reported reason of discharge from the HUC was the patients’ improvement. Meaning that the genetic sex of the patients was determined and the hormonal treatment to try to reverse / solve their sexual conditions was assigned. In these processes eight of these patients were mutilated to make them look anatomically like women and no information was found on the remaining patients, so we do not know what happened with their cases and their lives.
Medicine, thanks to its quality as an institution and its technological advances to monitor and control bodies, has been in charge of developing a procedure or protocol to be followed when intersexual bodies appear in their medical offices or delivery rooms. Based on the evidence collected through the interviews and medical records of intersex people, I could reconstruct in detail the protocol established in cases of intersexuality.
The medical protocol performed at the Hospital Universitario de Caracas can be divided into three stages: phenotypic, genotypic, and interventions. These phases are usually consecutive, complying with the order presented above and the last one may consist on a surgical or hormonal intervention.
In the phenotypic stage, the specialists are in charge of visually identifying the corporal characteristics of the person, through the revision and the measurement of the genitals to know if they fulfill the thickness or the length corresponding to the assigned sex. In other words, in this first stage, they seek to identify the external sex of people.
Doctor A: “The protocol, the first thing is to define the sex”
Doctor B: “That will depend on if you, according to what you see on the outside, that is… the phenotype… and according to the genotype because if it is a patient that has already determined female internal genital organs, if the genotype is male, then you have to transform everything that is outside … into feminine”
Doctor C: “I mean, visually I can identify that, it’s true. Because that will give me an orientation, but not only with the phenotypic part… with the form I will identify a sex”
Doctor A, the most experienced and specialized doctor in genital ambiguity , currently working in the hospital, has confirmed the aforementioned information. The doctor argued that the specialists’ analyses are based on average measurements, obtained through population-based statistical studies. All the data collected is analyzed using the Gauss distribution, in which the acceptable average and the excess or absence are delimited. In other words, the penises and clitoris of a sample of some population are measured, and from the average measure the genitals, the sexes and the lives of the new generations are regulated.
Doctor A gave us the average measurements they use:
- Penises: considered as such and functional when their size is above 1.5 cm (0.59 inches).
- Clitoris: considered as such when its size is below 2.5 cm (0.98 inches).
One of the most striking things about this data is that there is no positive limit for the size of the penis or a negative limit for the size of the clitoris. In other words, that a penis is larger than what is established as normal, does not place it within the category of pathology, nor does it question the correspondence of the person who possesses it with the sex considered masculine. The same goes for the clitoris, no matter how small or even absent it is. This does not question the correspondence of the person who has it, or not, with the sex considered female.
Why is it the medical and social interest that the penis should be large, while the clitoris should not be so prominent and may not even exist? Are medical decisions free of any ideology? It is quite the opposite, there is a heterosexist veil (endorsed by our Western society and therefore by the Venezuelan medical institution) that covers the faces of the wide range of medical specialists making them see straight-dominant-masculine-men and straight-submissive-feminine-women in each and every one of their operating rooms. This ideology seems to be more evident in the following step of the protocol.
In the second stage, the genotypic one, the specialists are responsible for clarifying the confusion that the external sex of the intersex people represents for the doctors What they could not identify on the outside, now they try to reveal it inside, in their genetic mark, their “true sex”, through the karyotype test, also known as chromosome counting or chromosomal analysis. This is one of the key stages within the protocol, since, based on the results obtained, the pattern to be followed will be dictated. According to the sexual truth revealed from the insides of the studied person, the interventions to be carried out in their bodies will be decided, respecting the convenience, stability and gender expectations of Venezuelan society.
Although, Doctors claim to respect and give more value to the sex chromosomes, they give more importance to genitals in the end. In other words, the karyotype test is almost meaningless.
Doctor A: “Of course, because if genotypically it is a male and you have nothing to work with… to do anything, you know that genotypically it is a male, but that you have to turn it into a female, after agreement with the parents “
Doctor C: “Sure, if I have suspicions. The consultation is with the geneticist, and once the fetus is born, and the newborn … The karyotype test is done and based on that, we do what is established in plastic surgery to reconstruct the areas. It is established in Venezuela, and besides that it is the easiest thing to do, that all those patients are transformed into female. Because although they can be males, they are transformed into female because the reconstruction of the genital apparatus towards the female one is much easier than the male one. From the functional point of view, to put it in some way “
In the third and final phase of the protocol, doctors try to make people fit, through surgical or hormonal interventions, within the male and female categories, reconfiguring their anatomy so that these people are men, and, mainly, functional women in the future.
The issue of functionality is key to understanding these procedures, since doctors seek that intersex people can carry out a satisfactory sexual life within the heterosexual logic, in other words, that they have penises that can actually penetrate and vaginas able to be penetrated. Among the most common reconstructive or reconfiguration surgical interventions are vaginoplasty, phallectomy, phalloplasty and clitorectomy, as well as a variety of hormonal treatments to address heterosexist and male-female logic in the development of genitals and secondary sexual characteristics.
Doctor A: “Four years ago she underwent vulvaginoplasty and clitorectomy”
Doctor C: “With this result and according to the characteristics of the external genitalia, appropriate surgical procedures would be carried out”
Doctor D: “Either it’s XX or it’s XY. If it’s XY… I know (that it’s a man), but what I’m going to do next, depending on what I get … how I can make it work (the penis)”
It is curious that most of the interventions that doctors carry out have the purpose of transforming intersex bodies into female bodies. They are the first option and seen as an advantage over the male ones. This is paradoxical, considering that the masculine body and male being is the dominant gender, hence the social ideal should be to masculinize the intersexual. However, due to the ideological basis on which the surgical arguments are constructed (and the so-called easiness of reconstructing ‘female’ body parts or lack of interest and intention), we could infer that this type of interventions beyond being a process of insertion of intersex people within the male and female categories, is a way of subordinating and interiorizing intersex people by feminizing them.
Some inconclusive remarks
In the present investigation, gender is understood as a way of interpreting bodies, and doctors carry out exercises of power through their speech and their protocols to normalize and guarantee bodies within the male and female categories. Therefore, it is evident that intersex people do not have a place within a society created by and for people who comply with this binarism.
Because of this, I propose to rethink the concept of sex beyond its biological sphere and from a queer perspective instead, in order to demonstrate the extent to which sex is nothing more than a patriarchal reading carried out on our biologically configured material bodies or a polysemic fiction, also transhistorical and pre-social, whose main function is to anchor, in an essential way, a series of gendered elements to the material reality of our bodies, through practice and biologist / naturalist discourse to produce and reproduce a sexual division, and therefore social, economic, political, symbolic and linguistic of the bodies.
The presence of intersex bodies is necessary evidence to demonstrate that sex goes beyond two categories such as male and female, and even allows us to question the binary conformation of two sexes-two genders (male-man and female-woman), since the supposed biological sex is unable to provide the solid and necessary information to justify the genders in only two types of sexes. In addition, the various genotypic and phenotypic causes of intersexuality break with the idea of only one criterion, which indicates that there is a hidden true sex in some corner of our bodies. As shown by the data obtained in this research, sex can be found in the genitals, in the gonads, in the hormones, in the chromosomes, among others, and, it is up to the medical team to decide which is seen as the truest of all.
Despite having a limited number of intersex cases in this research, I can demonstrate that the medical team of the Hospital Universitario de Caracas prioritizes the genital morphology of the intersex person when carrying out some assignment intervention (hormonal or surgical) and that they assign a greater number of women than men.
According to the information provided by the majority of the medical team interviewed, it is easier to eliminate structures than to build new ones, in other words, it is easier to create a vagina (supposedly a simple structure) than create a penis (supposedly a complex structure). This shows that the female condition is assumed and considered as the absence of something, in other words, the woman is characterized by the absence of a penis.
To conclude, I propose, based on the cases and on this research, to rethink the use of the term intersexual. Although up until now it has been very useful as a category of analysis and has allowed the opening of spaces for research, discussion and opposition towards the male-female categories, this term continues to limit non-dichotomous corporal expressions within the male-female borders. In other words, the word intersexual means between sexes, which leads us to understand that intersex people are halfway between a male and a female (the supposed clear, concrete and natural limits of sex), but nothing could be further from reality, since bodies are capable of presenting a variety of sexual combinations at different levels (phenotypic and genotypic), and we should oppose the idea that only those that are closer to the ideal of male and female should be considered natural and socially accepted.
Daniel Rodríguez Claveli is a Venezuelan anthropologist and languages teacher. Member of the academic LGBTTIQ organization, Contranatura UCV. He has been committed to LGBTTIQ rights, feminism and academic activism for the last 10 years. Since 2011, he has been doing a research about intersex people and how they are discriminated against and mistreated in Venezuelan hospitals. He has given lectures on intersexuality and medical discourse at national and international universities, conferences and LGBTTIQ workshops. He has also published some articles about inclusive language, intersexuality, sexism, and new masculinities in El Correo del Orinoco, a Venezuelan newspaper, and in academic journals.
Navarrete, R and Rodríguez Claveli, D 2013, ‘Presentación’, Revista Venezolana de Economía y Ciencias Sociales, vol. 19, no. 2-3, pp. 69-72.
Rodríguez Claveli, D 2017, ‘A ver qué traes entre piernas y diré quién eres: aproximación antropológica al discurso médico en casos de personas intersexuales en el Hospital Universitario de Caracas en el 2017’, B.S. in Anthropology, Caracas, Venezuela.