Abstract
I offer a reconstruction of contemporary medical procedures of sex assignment for infants with intersex conditions. In the perspective adopted, sex assignment to intersexed newborns can be understood as a procedure that imposes determinate sex predicates. The account describes two stages of sex assignment. At the first stage of the process, the sex predicates ‘female’, ‘male’, or ‘intersexed’ are taken to denote genital morphology. Initial genital assessment of newborns imposes clear boundaries upon the extensions of these predicates through diagnostic schemes of precisification. At the second stage, the sex predicates ‘female’ and ‘male’ denote sex of rearing, a therapeutic and pedagogical project aimed at producing stable and psycho-socially well-adjusted gender identity. The multi-dimensional indeterminacy of prognosticating sex of rearing at the second stage is mitigated through the prioritization of some subsets of the medical data.
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Notes
A recent exception is Helen Daly’s article (2015) in which Daly analyses stipulations by the International Olympic Committee as to who may compete in women’s events. Daly also includes a brief discussion of intersexed newborns, but her argument principally targets epistemicism as an approach to vagueness.
Karkazis (2008, p. 98) observes that “while clinicians and researchers routinely use the term intersex in the medical literature and among themselves, most of those interviewed told me they refrained from using this term with parents because, as Dr. B explains, ‘it carries the connotation of circus freak.’ To avoid this connotation, they tend to use the term ambiguous genitalia and present the situation as a solvable problem.”
Several authors refer indiscriminately to the vagueness of predicates and the vagueness of corresponding concepts. For my purposes nothing hinges on making a distinction between predicate and concept vagueness.
The inspection is often somewhat cursory, as lamented by a pediatric endocrinologist with respect to some obstetricians who “don’t examine the babies closely enough at birth and say things just by looking, before separating legs and looking at everything, and jump to conclusions, because 99 % of the time it’s correct…” (Kessler 1998, p. 17).
So-called AIS grades are similar. Neonates with Androgen Insensitivity Syndrome are born with 46 XY chromosomes and testes but their tissues are partially or completely insensitive to androgens. The morphology of their external genitals can vary considerably and is sometimes ranked on a scale from 1 (“fully virilised”) to 7 (“fully feminized”). Recommendations—such as those of Diamond and Sigmundsen (1997), for example—attempt to introduce a standard of classification: neonates with AIS grades 1–3 are to be raised as males; those with AIS grades 4–7 are to be raised as females. As Karkazis remarks: “This recommendation, of course, raises the question of where exactly the clinician should draw the line between grades 3 and 4” (2008, p. 120).
Sorensen (2010, p. 404) argues that it is a vague matter whether some predicates, for example ‘zillion’, can be used to construct a sorites argument or not. Perhaps, then, it is a vague matter whether genital sex predicates are soritically (linearly) vague or not. If this is so, by claiming that my account is accurate enough for my purposes, I am effectively stipulating a precise meaning for the predicate ‘vague’ when qualifying the sex of the genitalia of neonates.
Various alternative theories of vagueness explain how (B) is false, neither true nor false, not definitely true, or less than perfectly true (Graf 2001 p. 907). See Keefe (2000) and Hyde (2010) for useful expositions of various theories of vagueness. One can also bite the bullet and claim that our language is simply inconsistent, although still functionally useful in some way provided the vagueness can be ignored or remains hidden.
Note that the additional tests are, themselves, subject to vagueness. It may not be clear, for example, whether testosterone or dihydrotestosterone concentrations in the blood lie within the typically ‘male’ range.
Malone et al. (2012, p. 586) note that “[a] common criticism of the Prader classification and the EMS is that there is no correlation between the degree of external virilisation and the level of the confluence between the vagina and urethra.” The PVE classification, developed by Rink et al (2005) incorporates the Prader classification and specifically takes vaginal-urethral confluence into account. However, it is a tool designed to facilitate surgical outcome research rather than initial sex assessment.
Following Lewis (1986), Keefe characterises semantic indecision as follows: “It is commonly said that vagueness is a matter of semantic indecision. No single one of F’s precisifications can be correctly identified as providing the extension of F, because the meaning of vague F is such as to leave the choice between them unsettled.” (Keefe 2000, p. 155).
Such a solution may be socially and ethically preferable as some authors have intimated (Fausto-Sterling 2000, 2012) but in the present article I will not adopt a firm position on which intersex conditions could be de-pathologised. This is partly because—as I have indicated—some intersex conditions are life-threatening conditions. In particular, it is problematic to accept salt-washing CAH and some forms of non-mosaic aneuploidy (as exhibited in Kleinfelter and Turner syndromes) as sex categories. I would like to thank an anonymous reviewer for insisting that I clarify my position on this point.
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Acknowledgments
An earlier version of this paper was presented at a talk given at the Canadian Philosophical Association meeting at Brock University in May, 2014. I would like to thank those present, particularly Rebecca Mason, for their incisive comments. I would also like to thank Robert Stainton for helping me clarify some of the issues addressed in the article.
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Kapusta, S.J. Intersex Diagnostics and Prognostics: Imposing Sex-Predicate Determinacy. Topoi 36, 539–548 (2017). https://doi.org/10.1007/s11245-015-9354-z
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DOI: https://doi.org/10.1007/s11245-015-9354-z