Page 3 - My Project1

W e are defined by sexual dimorphism.

Male and female, the sexes we are (and are perceived to be), affect how we feel, how we behave and how we interact with others. We look around and see all complex creatures, including ourselves, as either male or female. This is so much a part of our daily existence that it reinforces the idea of man-hood and womanhood as expressions of a natural order. We regard this division into two sexes as one of the great eternal verities and tend to experience the difference between the sexes as rather absolute. Subjectively, man and woman are seen as opposites, poles apart and mutually exclusive forms of human existence.

In daily medical practice, this duality of the sexes also tends to be regarded as axio-matic. The biological determinants of male and female somatic sexual differentiation have been elucidated and these insights have contributed substantially to the defini-tion and diagnosis of errors of sexual dif-ferentiation. As a result, when such errors are encountered, treatments can often be provided to enable subjects to lead more conformable lives as men and women. In some exceptional cases, however, normal medical practice is unable to offer solace to subjects whose manhood or womanhood is troubled.

This contribution looks at some of these unusual conditions. It addresses the sex assign-ment of newborns afflicted with sexual differ-entiation errors as well as the phenomenon of transsexualism. Both conditions have their biological aspects, but both also have ramifica-tions into the psychosexual and psychosocial aspects of manhood and womanhood. Both

BOYS AND GIRLS, MEN AND WOMEN Since time immemorial, parents have as-signed their newborns to the sex indicated by the morphology of the external genitalia. This empirically based practice seems reas-onable enough as it has withstood the test of time; babies that appear to be boys or girls at birth generally do grow up to become norm-ally functioning adult men and women. This means that no major intentional (pedagogic) effort is required to mould baby boys into men and baby girls into women. Manhood and womanhood seem to be intrinsic, bio-logically determined properties of boys and girls requiring only completion by the hor-mones of puberty to fully express sexual dif-ferentiation and bring about the erotosexual interaction between the two sexes. As the lat-ter is essential for species survival, this would seem to be an inherent, biologically ordained property of all living organisms that depend on sexual reproduction.

The perception of manhood and woman-hood as being complementary and this being necessarily so for the survival of the species, has led to the belief that the full spectrum of masculinity and femininity is the product of biological determinism. The strong parallels with the animal kingdom have reinforced this belief. In the biological sciences, the sexual interaction between the sexes is teleologically equated with repro-duction. Carnal desire and pleasure are viewed as an embellishment of the incentive to procreate, and not as goals in themselves. The equation of sexuality with procreation has reinforced the idea that man and woman are mutually exclusive but inter-dependent poles, each presupposing the other and neither existing on its own.

INTERSEXED STATES

It has been part of the human experience that some babies at birth will present ambiguities of the genitalia. The homespun wisdom of medically unsophisticated people would usu-ally guide them to assign the baby to the sex it most closely resembled in external genital appearance on the assumption that nature’s ‘intentions’ were thus best heeded. After all, this is merely an extension of the existing common practice which assumes that the present and future masculinity and feminin-ity can be inferred from a (casual) inspection of the external genitalia.

As is often the case, this commonsense approach is in fact sensible. As the research of Professor John Money from 1950 on has clearly demonstrated, in children with ambigu-ous genitalia, the sex that a child is assigned and reared in is a significant factor in future self-awareness of being male or female, 1

though other factors, mainly prenatal exposure to androgens, should not be dismissed. Trying to ‘read nature’s intentions’ in regard to the sex of the newborn took a dif-ferent turn and gained scientific momentum when the biological principles governing the development of male and female gonads and genitalia were gradually elucidated starting from the middle of the 19th century. The microscopic examination of the gonad and its classification as ovary or testis was the basis of Klebs’s classification of hermaphroditism from 1876. 2 Klebs recognized true hermaph-rodites as possessing both ovarian and testicu-lar tissue. This was in contrast to pseudo-hermaphrodites, who possessed either an ovary with genitalia that appeared male, or a testis with female-like genitalia. Klebs and his contemporaries assumed that the gonadal tis-sue would determine the ‘true’ core sex, including sexual outlook and sexual desires, even in those cases where the actual genital status and later self-awareness of being man or woman, was at odds with the nature of the