How the Clinic Made Gender: The Medical History of a Transformative Idea by Sandra Eder (review)

This important book tells the complicated history of the origins of gender as a concept originating in the clinical evaluation of intersex children in the 1940s and 1950s before it was embraced by psychology and the social sciences and, finally, by feminism and political theory. Sandra Eder describes the shift from sex to gender not as a paradigmatic break but as a gradual transition that preserved a "feedback loop between the biological and the social" (5). This is largely an American story highlighting the role of the social and cultural value systems of the postwar United States in the effort to return to "normal," strengthen the family, and raise children who would be happy and productive. Eder combines these broad historical themes with granular investigations of the clinical sites where medical decisions were made about how to treat and manage intersex cases in a way that assured patients' well-being and social integration.

The psychologist John Money is often credited with first using the term gender to highlight the environmental and social influences on intersex children raised as either boys or girls, but Eder effectively shows that it was the pediatric endocrinology clinic run by Lawson Wilkins in the Harriet Lane Home for Invalid Children at Johns Hopkins Medical School that developed the protocols for the case management of "hermaphroditic" children, as they were mostly called then. Money finished his dissertation in the Department of Social Relations at Harvard in 1952 and joined Wilkins's clinical team later that year. By then, Wilkins had abandoned treatments that attempted to discover the "true sex" of his patients and surgically reconstruct their ambiguous genitalia to that standard. Instead, he began by discerning in interviews with parents the sex in which children were being raised and based his surgical interventions on that. When Money joined the staff, he reviewed all the earlier case studies and interviewed and tested the children to find clues about their psychological sex. By 1956 he was using "gender role" as a simulacrum of psychological sex and drew upon popular contemporary social and cultural theories about the shaping power of the environment to justify raising intersex children as boys or girls. Parsonian sociology and the imprinting mechanisms observed in birds by Konrad Lorenz were regularly referenced by some of Money's acolytes.

By the mid-1950s cortisone had been found to treat the most common of intersex conditions, congenital adrenal hyperplasia (CAH), which masculinized predominantly female intersex children. These children had previously been surgically altered to be boys, but long-term cortisone treatment retarded masculinization, and the decision was often made to raise them as girls. By following the strategy of excising enlarged clitorises and creating vaginal openings, or preserving a rudimentary penis, and recommending the first group be raised as girls and the second as boys, Money's protocols expressed confidence that the sex of rearing (gender role) would prevail over either chromosomal or gonadal sex. This comforted both parents and doctors, who could now make more confident decisions about raising a child who would become a functional and happy adult.

Eder makes clear the extent to which medical experts, parents, and case managers tried to implement the midcentury ideals of clear gender distinctiveness, heterosexuality, social functionality, and personal happiness. Children who doubted or resisted their assigned sex, or a predominantly female child raised as a boy but attracted to males, were regarded as failures. Eder had access to case notes and interviews conducted at the Hopkins clinic that clearly indicate the concerns and speculations of the experts about potential deviations from gender norms and sexual orientations. As Money and many of the other experts admitted, hermaphroditism provided medicine the possibility of experimentation with surgical, endocrinal, behavioral, and other treatments for aligning patients with the sex they could comfortably inhabit and permit them to marry and even have families. Parents were...