Some Things Haven't Changed in Intersexuality

The legal and social imperative for clear binary sex categories led medieval surgeons (starting around the 13th through 14th century) to propose “correcting” anomalous bodies. This chapter traces several different surgical traditions, in a context where manuals of surgery were attempting to create a more professional approach to the surgical field in general.

These surgical traditions addressed several types of non-normative bodies, including “hermaphrodites,” impotent men, eunuchs, and women with what were considered enlarged genitals.

Prior to the 13th century, surgery was considered less professional than medicine, learned by apprenticeship rather than formal study. But in the 13th century some practitioners in Italy and France began to professionalize the field, including the creation of manuals of practice. Much of this chapter focuses specifically on the Parisian surgeon Lanfranc of Milan. This was part of a more general increase in professionalization and regulation of healthcare. Surgeons were struggling to establish their field as independent from physicians, as well as expanding into new fields of application, including treatments that might be classified as “cosmetic surgery.” There was also an expansion deeper into women’s medicine, including reproduction.

Within this context, surgeons claimed expertise in how to evaluate ambiguous bodies to determine not only “what sex predominated” (in appearance and function), but how to modify the body to more closely resemble the norms of the assigned sex. (Note: DeVun is probably reflecting medieval attitudes and priorities and describing this as evaluation “whether or not the patient was masculine enough to achieve male status or two feminine to qualify.”]

Arabic texts were, as usual, a major source of theories and approaches, which included the removal of body parts that didn’t fit a binary category. The situations and surgical practices to address non-binary bodies are presented in Arabic manual side-by-side with techniques for circumcision and female genital cutting (of “normal” bodies). The latter can make it difficult to draw clear lines between “correcting” intersex bodies and modifying female bodies to control women’s sexuality. These Arabic manuals were translated and disseminated in Europe in the 12th to 14th centuries.

The surgical manuals recommended various methods for determining which sex to attempt to target. A common approach was based on how and where the patient was able to urinate. For bodies assigned female, the goal was to enable penetrative intercourse (and, theoretically, conception although hormonal considerations were outside their knowledge). This also involved removing any penis-like tissue on the assumption that it would get in the way. For a male-assigned body, the goal would be to close any unwanted genital openings.

A different approach assigned sex based on the method of sexual arousal. This would allow male assignment if the patient experienced arousal via any penis-like organ of whatever size. (Note: this was before the “rediscovery” of the clitoris as the primary source of female arousal in the 16th century.) This metric shifted the dividing line for sex assignment.

The manuals offered various cautions. The patient must not be prevented from urinating. Anything evaluated as a functional penis must not be removed. [Note: I’m avoiding discussing specific surgical techniques in detail as they are not directly relevant to the Project and reading them could be unnecessarily traumatic. Read DeVun if you’re interested.]

The surgical approach operated on the theory that all bodies actually had a binary sex and it was only a matter of modifying the anatomy to match it. The metric that sex could be assigned on the basis of arousal—which seems to have been applied in the case where determining whether a penis-like organ was sufficient to prove masculinity—has a parallel in tests for male impotence. If the subject could not be aroused by a woman to the point of erection (sometimes requiring ejaculation) then they failed the test. (Sometimes prostitutes were hired to perform the test.) [Note: this once again points out the overlap of intersex and lesbian issues, as the “arousal test” assumes heterosexual desire.] There is further discussion of impotence tests. A man judged to be impotent might be forbidden to marry (or have his marriage annulled) but would not result in him losing the legal status of a man.

The chapter also discusses the categorization of eunuchs, whether created or unintentional (which could include some types of intersex). Due to the importance of procreative potential insect classification, they could not be classified as either male or female.

The female equivalent of male impotence was generally an anatomical inability to receive penetration.

Surgical manuals distinguished non-binary bodies that were preponderantly feminine but had some masculine features from female bodies whose genitals were perceived to be excessively large. Although the motif of the macro-clitoral lesbian was yet to be established, Arabic manuals and European successors considered an overly large clitoris—especially when capable of erection—to be undesirable, and recommended removal. Avicenna does record a belief that a large clitoris could cause a woman to desire sex with women. Based on the wording, the rationale appears to be that because the organ resembles a penis, the woman will naturally try to use it as one, which by logic would require a female partner. But another rationale was that a male partner would find the organ offputting. [Note: The general belief in this era was that women derived sexual pleasure from penetration, therefore removal of the clitoris was not necessarily intended to prevent sexual pleasure.]

The evaluation of ambiguous genitals was based on additional factors besides shape and size. Stereotypes about maleness (strong, hard) and femaleness (soft, week) could position someone relative to male and female prototypes. “Softness” in men was associated with sexuality and effeminacy. Luxury and vanity were considered to make men less manly and thus a danger to the integrity of the state. The evaluation of conventional attractiveness was more often applied to female-classified bodies. One reason offered for removal of a large clitoris was that it was “ugly.”

The surgical manuals (as contrasted with a few of the legal texts) make no consideration of the patient’s expressed identity or wishes, the one manual note that in the case of those who were (anatomically) capable of taking either an insertive or receptive role in sex, “one should put to them…what nature they would want” and surgically remove the other option.

It isn’t clear to what extent sex-assignment surgeries were performed in the medieval era, or to what extent they were “successful” if so. There are very rare mentions of surgery being recommended to or performed on specific named individuals (as opposed to the theoretical advice in the manuals) but surgeons do seem to have been brought in as sex-assignment consultants, went available.

The complexities of evaluating non-binary bodies as detailed in medieval texts don’t rigidly follow the “one-sex” theory as detailed by Laqueur. For example, although the one-sex theory considers the penis analogous to the uterus (one being an inversion of the other), the surgical texts clearly compare the penis and clitoris when evaluating the “preponderance of evidence.” Nor was individual identity/preference as influential in pre-modern times as has been suggested by Foucault.

The final section of the chapter compares medieval and modern approaches to non-binary bodies, and finds little substantial difference in the underlying philosophy. There is also a discussion of the usefulness of interrogating medieval understandings of non-binary people through a trans lens. Given the way in which medieval thinking conflated sex, gender, and sexuality, identifying a medieval person as “transgender” is as anachronistic as identifying them as “homosexual”—which isn’t to say that the behaviors associated with either were not present, only that there was no cultural concept that matched those modern categories. [Note: see my essay on comparing cultural categories as “translating prepositions.”]