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.
But this intricate and elegant
development of external and internal sexual organs is
a journey prone to detours caused by all sorts of influences
like maternal hormones, drugs, genetic disposition,
environmental hazards, and chance. Sometimes clitorises
look more like penises. Sometimes the outer labia on
a girl baby fuse into a scrotal-looking sac so her genitals
may appear almost indistinguishable from a typical newborn
baby boy's. Sometimes a boy's scrotum is empty, his
testes undescended, and his penis tiny. Some vaginas
end before they reach the uterus.
These variations occur more frequently
than most of us assume. According to Anne Fausto-Sterling,
professor of biology and women's studies at Brown University,
and author of Sexing the Body: Gender Politics and
the Construction of Sexuality, in almost 2 percent
of live births, or approximately 80,000 births a year,
there is some genital anomaly. And out of those, about
2,600 children a year are born with genitals that are
not instantly recognizable as female or male. Once Baker
Brown's methods fell into disfavor, most such children,
if born in the U.S. in the first half of the century
with non-life-threatening differences, would have been
left alone to navigate the world with genitals that
someone might notice as odd. But by the 1950s, attitudes
toward intervention were changing. Research by  John
Money, a young sexologist at Johns Hopkins University,
suggested that a child's genitals could be altered during
the first 18 months of life without undue problems for
that child. Along with improved surgical skills and
commercially available hormones, this led medicine into
a protocol of intervention that still stands. If a girl's
clitoris looks a bit too much like a penis, then all
or part should be removed. If a boy's penis is too small
to function as a "real" man's, that boy would be better
raised as a girl, his penis pared down to approximate
a clitoris, and his body further altered by hormones
and surgery to look female. This remains a practical,
not a theoretical, protocol. Approximately 2,000 children
a year have genital surgery in the U.S. Experts say
the vast majority are girls who lose parts of their
clitorises and, less commonly, little boys who are changed
into girls in an attempt to give them what doctors believe
will be a better life.
These children are called intersexed
by the medical world, no matter what their chromosomal
makeup. Surgeons perform cosmetic genital surgeries
on these children so that they, their parents, and caregivers
will have an unwavering notion of them as one sex or
the other.
Most modern surgeons prefer techniques
that strive for a better cosmetic result than the "clear-cut"
look of earlier procedures. (Though as pediatric urologist
Kenneth Glassberg points out, "good cosmetic appearance
does not guarantee good sexual function.") All procedures
to remove or change the appearance of the clitoris are
now grouped under the term "clitoroplasty"-—a word
coined in the early 1970s as an inclusive term and perhaps
as a way to distance new surgical techniques from the
old. Clitoroplasty can be part of a broader procedure
called "feminizing genitoplasty" that includes the building
of a vagina and the fashioning of labia to make a more
feminine-looking genital area.
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