Making the Cut: It's a Girl! ... Or is it? When There's Doubt, Why are Surgeons Calling the Shots.
by Martha Coventry
On New Year's Eve, I sit with an acquaintance and talk. We are nearing the end of a long, pleasant evening. My friend, also a writer, leans toward me into the little circle of privacy we've created. "So you mean what happens to African girls?" she asks, after I tell her what I am working on. "No," I say. "I mean what happens to children in the United States." And as I explain the details of the story, she earnestly watches my face, then sits back, stunned. "I am astonished," she says, and I have to agree with her. It is an astonishing story.
The tale begins in England. It is 1858, and the Victorian Age is in full swing. A respected gynecologist named Isaac Baker Brown, who later served as president of the Medical Society of London, has an interesting theory about women: most of their diseases, he believes, can be attributed to over-excitement of the nervous system, and the pudic nerve, which runs into the clitoris, is particularly powerful. When aggravated by habitual stimulation, this nerve puts undue stress on the health of women. He lists what he calls the eight stages of progressive disease triggered by masturbation: first comes hysteria, followed by spinal irritation, hysterical epilepsy, cataleptic fits, epileptic fits, idiocy, mania, and finally, death.
Baker Brown wasn't alone in his focus on "excessive venereal indulgence." A cultural obsession with masturbation had been building since the end of the eighteenth century and would reach its zenith in Britain and the U.S. in the early 1900s. Various methods had been tried for decades to curb the habit in girls and women, including applying caustic substances to the clitoris and vulva to produce a chronic sore, but masturbation continued unabated. Its consequences, believed to be chiefly hysteria and epilepsy, were becoming nearly epidemic in some people's opinion. The cure Baker Brown offered was complete excision of the clitoris with scissors, packing the wound with lint, administering opium via the rectum, and strictly observing the patient. Within a month, the wound usually healed, and according to Baker Brown, intractable women became happy wives; rebellious teenage girls settled back into the bosom of their families; and married women formerly averse to sexual duties became pregnant.
Physicians had been recommending clitoridectomy for masturbation since the writings of ibn Sina, the tenth-century Persian scholar, but it never became a regular procedure. And they had been removing clitorises that were diseased or so large they interfered with intercourse for at least a century before Baker Brown. But what made Baker Brown the "inventor" of the medical clitoridectomy was his sterling reputation, the scale on which he carried out his surgeries, and the fact that he popularized his method in a book called On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females.
Eventually Baker Brown fell out of favor with a medical establishment that would have preferred more discretion about women's genitals. But before his fall from grace, Baker Brown influenced U.S. doctors, who were discussing his procedure in medical journals by 1866. It was used off and on for decades to stop masturbation, nymphomania, and hysteria. In 1894, a surgeon reported in the New Orleans Medical and Surgical Journal that he had excised the clitoris of a 2 1/2-year-old to stop her from masturbating and slipping into insanity. He noted that after the operation, she had "grown stouter, more playful, and (had) ceased masturbating entirely." As late as 1937, Holt's Diseases of Infancy and Childhood, a respected medical-school text, stated that the author was "not averse to circumcision in girls or cauterization of the clitoris." A couple of years ago, I spoke with a 66-year-old woman in Michigan who had a secret to tell me: as a 12-year-old in 1944, her parents took her on a car ride that ended at a doctor's office. There, as she sat on the exam table, an attendant clamped an ether-soaked rag over her mouth from behind. When she woke up, her clitoris was gone. "They tried to keep me from masturbating," she said. Then, after a pause, added, "Didn't work."
Toward the middle of the 1950s, just as U.S. medicine seemed to be awakening to the brutality and ineffectiveness of clitoridectomies as a means to control behavior, it found another use for the procedure. This time the rationale was that the operation could be used to make a child whose clitoris appeared bigger than other girls' look "normal," thus helping the child, and everyone around her, feel more comfortable. In 1966, a full century after Baker Brown's clitoridectomies were first discussed in this country, this recommendation appeared in the Journal of Surgery: "Some persons have been reluctant to advocate excision of even the most grotesquely enlarged clitoris. . . . half-way measures are much less satisfactory than complete clitoridectomy." Given this attitude, in 1966, was any girl in the U.S. whose clitoris protruded noticeably beyond her labia at risk of getting it amputated? Yes. Would a girl in the year 2000 still be at risk of losing at least part of her clitoris? Yes.
The rationale for clitoridectomy in Baker Brown's time was straightforwardly terrible, and ridiculously unscientific. By contrast, modern theories seem slightly more humane, but when you get down to it, the same question of gender links the Victorian Age's clitoridectomy to its Dot-Com Age cousin. We have been altering the healthy genitals of our children-—boys as well as girls-—for 135 years so that a girl will look and act like a girl, and a boy will look and act like a boy, according to social norms. The strict division between female and male bodies and behavior is our most cherished and comforting truth. Mess with that bedrock belief, and the ground beneath our feet starts to tremble.
To begin with, we rely on the notion that the bodies of females and males are distinctly different. We imagine a dividing line with penis, scrotum, testicles, testosterone, and XY chromosomes on one side, and clitoris, vagina, uterus, ovaries, estrogen, and XX chromosomes on the other. But were we to look between the legs and into the chemical and chromosomal makeup of real people, we would see that nature often refuses to abide by that tidy division.
Over the past 50 years, medicine has established standards for female and male bodies. Girls, if they want to perceive themselves, or be perceived, as fully "feminine," should have clitorises no longer than about 3/8 inch at birth. Boys, if they hope to grow up "masculine," should have penises that are about one inch in stretched length at birth. (Variation in phallus length can be a sign of an underlying medical problem, but it is also used for nonmedical judgments about "normality.") Girls should have vaginas fit for future intercourse, and boys should have urethral openings at the tip of the penis.
By eight weeks gestation, all external fetal genitals have the potential to develop into what we think of as female or male genitals. The genitals will become female if testosterone, or a hormone that mimics testosterone, does not interfere. If it does, then the clitoris extends to make a penis and the inner labia wrap around the underside of the penis and fuse to form the penile urethra. The outer labia come together to create the scrotum. The process for the internal sexual organs is similar. All fetuses start out with precursors of female and male sex organs. By the third fetal month, if the rudimentary male ducts have not been triggered to mature into testes and vas deferens, they will disappear. The female ducts will then grow and develop into ovaries and a uterus.
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