At the level of identity, genitals are made neither in the womb, nor in surgery, but in the mind.
Thinking critically about genitals—how they look, what they are, what they mean—feels like repeating a familiar word so many times that it starts to sound weird and implausible. The physical properties of genitals feel certain, but the material of this certainty is often hazy guesswork, drawn less from experience than from the imaginative processes that give our ideas of things substance in the mind.
As we grow up, many of us build our idea of genitals from a patchwork of clumsy childhood discoveries, chaste textbook renderings, and the aesthetic valorized in mainstream porn. This early understanding of what genitals should look like can even survive encounters with bodies that don’t correspond to it. Reality apparently doesn’t always have sufficient power to undermine our fixed and abstract mental images. It’s as if the idea of genitals is more real than their physical form, or the latter is real only insofar as it confirms the former.
This is partly because commonplace concepts of gender treat biological sex as determinative in a violent logic: Genitals means sex means gender. Essentialist accounts of gender appeal to medical science to reiterate a mind/body or gender/sex binary, without considering how scientific truth claims are shaped by the paradigm from which they have emerged. These accounts are often at odds with some of the physical realities they describe, such as the prevalence of sex chromosomes beyond XX/XY, or external genitalia that don’t resemble traditional archetypes of penis-testicles and vulva-clitoris-vagina.
When I studied anatomy, we learned the prescriptive architecture of biological sex as if it were inevitable fact. Yet our textbooks included depictions of bodies that didn’t conform to the supposedly universal forms, presenting them as strange and pathological. In medical school, few people could see that the very existence of these bodies was an effective critique of the certainty of biological sex. Outside the framework of my studies, I became increasingly suspicious of normative standards of sex and gender. Armed with experiences and critiques drawn from elsewhere in my life, I grew more and more critical of how medicine understands and processes gender by excluding those bodies that cannot be coherently inscribed into the present gender regime.
Even by medicine’s own scientific account, the human body does not automatically provide us with a strong distinction between “maleness” and “femaleness.” In early fetal development, the cells that go on to form reproductive tracts and genitals are initially indifferent, regardless of the embryo’s sex chromosomes. The building blocks for all reproductive and genital eventualities exist in the early embryo concurrently, waiting for cues. For the first trimester the external genitals remain indistinguishable: Each anatomical aspect has the genetic potential to be another with the right encouragement (glans of penis or glans of clitoris, surface of penis or labia minora, scrotum or labia majora, or in variable combinations of neither).
When a baby is born, if doctors think its genitals deviate from the expected norm, its body is surgically reconfigured. These bodies that differ from the genital ideal are often seen as aberrations. When we try to reflect objectively on how bodies are understood as “male” or “female,” we can see that the popular understanding of genitals as either/or doesn’t reflect the reality that the potential forms of external genitalia are in fact unpredictably multiple.
The idea that genitals have multiple potentials and that we can build them to fit our idea of them is important when it comes to genital reassignment surgery. This elegant surgery reconfigures anatomy on an aesthetic, functional and sensual level. Metoidoplasties, for example, bring forward the clitoris and unite it with skin from the labia to form a functional penis and scrotum. Phalloplasties involve taking skin from the arm or abdomen to produce a functional penis that, with an implanted device, can sustain erections capable of penetrative sex. In both phalloplasty and metoidoplasty, the presence of a former clitoris as the new penis head provides the same arc of sensation that transmits as sexual pleasure. In vaginoplasties where a new vagina is formed, the head of the former penis relocates to become the clitoris, while inversion of the remaining penile skin and scrotum produces a fully sensate vagina. (These are technical terms and don’t necessarily reflect the patients’ preferred terms for their genitals.)
Not all trans people choose surgical treatments, but for those who do, studies demonstrate that genital-reassignment surgery is very effective. Individuals report relief of the symptoms of their dysphoria, low rates of regret, and high levels of patient satisfaction. The data that demonstrates this may rely on grim cost-benefit analyses of medical interventions, but they clearly show that gender treatments make a difference in the lives of many trans people. Gender surgery, like all surgery, reconfigures a body’s capacity to meet its own needs and, as such, can mean as much or as little of anything to anyone. For many I’ve seen, it can offer some liberation not only from dysphoria but also from the oppression they face when navigating gender in social contexts—being able to use gendered toilets without the fear of violence, or having the type of sex they want to have. Post-gender critiques that remonstrate against gender surgery for upholding physical gender norms re-enact the oppression they pretend to fight. I suspect they arise from an inability or refusal to conceive of others’ gender dysphoria. These critiques imply that trans individuals are to blame for somehow inadequately dealing with oppression.
It’s clear that there is no universal experience of dysphoria. Many trans people experience no genital dysphoria at all. For some, dysphoria is concentrated around noticing the incongruence between the gender they understand themselves as and the gender they are assigned. For others, dysphoria exerts itself as a visceral weight that can cause as much pain as physical injury, an unconscious process in which the body is the passive recipient of its distress.
Critics of gender surgery may be right that the link between genital anatomy and gender is dubious, but trying to deny trans people important surgery puts the emphasis in entirely the wrong place. In fact, more careful thought shows that the bodies of cis-gendered individuals have an equally problematic relationship to biological sex. Cis people’s identification of their anatomy with their gender also relies on the residual power the idealized forms of genitals have in our imagination. These forms are only attempts to capture reality, and are not reality itself. At the level of identity, genitals are made neither in the womb, nor in surgery, but in the mind.
Some accounts of the social construction of gender still maintain biological sex as a kind of underlying basis, to be either tolerated or changed. But the more I read and the more I see, the less certain I am about biological sex. Perhaps the body doesn’t automatically suggest gender as much as we think but has to be given a gender in order to operate in the world. If biological sex is less a case of a simple binary with pathologized aberrations and more like a spectrum, where does the binary originate from, how does science uphold it, and what motivates it to do so?
It could be that it arises from a tendency to explain the most things in the simplest possible terms, which would make sense given the relatively low prevalence of non-XX/XY chromosomes and ambiguous genitalia at birth. But even by this account, the perception of some people’s genital anatomy as normal relies on a socially upheld idea of gender. Bio-essentialist theories of gender are, ironically, inadequate as descriptions of the human body; all they account for is the persistence of the social construction of gender.
Born-this-way gender biology is a historical accumulation of empirical findings and personal subjectivities, precariously held together by the veneer of objective reality afforded by scientific method. The male/female binary is perpetuated by the myth that sex chromosomes are XX or XY, and XX and XY are perfectly formed penises or vaginas, and perfectly formed penises or vaginas are boys or girls, with all deviations from this entering the realm of pathology. But the idea that the body exists objectively is false. External genitals, like all other aspects of gender, are the result of interpretation. They can be reinterpreted.