No Quick Fix

Since 1990, when Suzanne J. Kessler published her watershed essay "The Medical Construction of Gender: Case Management of Intersexual Infants" in Signs, intersex studies have come to constitute a substantive field in gender and sexuality studies.¹ Intersex—the umbrella diagnostic term for hormonal and chromosomal conditions that present with ambiguously sexed genitalia at birth—has raised ethical and theoretical questions about what exactly biological sex signifies and how cultural understandings of sex become simultaneously confounded and consolidated at the site of sexual indeterminacy. Katrina Karkazis's excellent Fixing Sex is an anthropological investigation into the triangulation of clinical medicine, intersexed persons, and parents. Written in three parts, Karkazis offers the reader a succinct history of the medical management of intersex since the late nineteenth century, an ethnographic account of intersex treatment in the contemporary clinical milieu, and a measured inquiry into the variety of issues faced by people who have intersex conditions, or "disorders of sexual development" (DSD), and their parents. Informed by a range of theoretical contexts—including feminist and queer theories about the historical and linguistic production of gender and a critical science studies approach to the cultural production of medical discourse—Karkazis wrestles with the ongoing conflict between cultural and biomedical understandings of the physical body. Ultimately, the project poses crucial questions about what clinicians have presumed to be the physical conditions necessary to produce a coherent gender subjectivity, with a focus on the appearance of the genitals, and how these presumptions have been tainted by heteronormativity.

Fixing Sex differs from other recently published monographs on intersex in several ways. First, as Karkazis asserts in the introduction, it is the first ethnographic study of intersex since the emergence of intersex activism in the mid-1990s (15). Her study thus reflects the effects of intersex activism on medical practice, in public discourse, and in the lives of people with intersex conditions. Second, it is the only study of its kind to look specifically at how discourse about intersex is produced first and foremost through the triangulation that Karkazis poses between clinicians, intersex subjects, and parents. Finally, Karkazis has harnessed an approach to her topic that is unilaterally empathetic: she represents all of the players in her triangulation as products of the broader cultural imperative to produce and maintain a two-sex, two-gender system. Although it is the intersexed people she interviews who have the greatest insight into the limitations of this system, parents and clinicians are never vilified. The effect of this strategy is an especially persuasive account of how intersex exceeds the bounds of binary sex. Ultimately, as clinical standards continue to shift, Karkazis asks that a host of factors be included in the early natal decisions that are made in cases of intersex/DSD. These include a de-emphasis on the external appearance of the genitals, greater consideration of sexual pleasure both in treatment practices and in outcome studies, reconsideration of heterosexuality as evidence of a successful or coherent gender identity, and revisions to the double standard that has traditionally prioritized reproductivity in 46, XX DSD (previously female pseudo-hermaphroditism, ideally raised female) and sexual function in 46, XY DSD (previously male pseudohermaphroditism, typically raised male when the size of the phallus is large enough to permit penetrative sexual intercourse).

As the subtitle suggests, Fixing Sex is not only about mending or repairing intersex conditions but asks whether these primarily cosmetic fixes are necessary in the first place. Karkazis broadly investigates how intersex management has been used to bolster preconceived notions, both medical and cultural, about sex and gender difference. Indeed, the second and third parts of Karkazis's study vividly illustrate how clinical approaches to intersex have had a deeply stabilizing effect, firmly linking gender identity to the appearance of the genitals and, more recently, to the chromosomes. Significantly, in chapter 4, Karkazis documents a shift that has taken place in intersex gender assignment, from making male gender assignments based primarily on the size of the phallus to placing greater emphasis on chromosomal sex, especially...