There is hardly a word in the English language comparable to the word "sex" in its vagueness and in its emotional content. It seems definite (male or female) and yet is indefinite (as we will see). The more sex is studied in its nature and implications, the more it loses an exact scientific meaning. The anatomical structures, so sacred to many, come nearer and nearer to being dethroned. Only the social and legal significances of sex emerge and remain.
According to the dictionary, sex is synonymous with gender. But, in actuality, this is not true. It will become apparent in the following pages that "sex" is more applicable where there is the implication of sexuality, of libido, and of sexual activity. "Gender" is the nonsexual side of sex. As someone once expressed it: Gender is located above, and sex below the belt. This differentiation, however, cannot always be very sharp or constant and therefore, to avoid pedantry, sex and gender must, here and there, be used interchangeably.
With the advancement of biologic and especially of genetic studies, the concept of "male" and "female" has become rather uncertain. There is no longer an absolute division (dichotomy). The dominant status of the genital organs for the determination of ones sex has been shaken, at least in the world of science.
Furthermore, there is also the psychological reaction to sex, which is widely different in different individuals. It means one thing to an objective scientist, for instance such a man as Kinsey. It means an entirely different thing to a fanatical and antisexual crusader such as Comstock. A Brigitte Bardot will look at sex in her own way, and so will the courtesan. The average citizen may not identify himself or herself with any of these interpretations but will have his or her own concepts and ideas as to what sex means or should mean.
The biologist, the medical man and clinician, the psychologist, the jurist, the sociologist, and finally the priest and theologian are all apt to view and study sex from different angles and in different lights. In some instances, sex means gender; in others, it means sexuality, sex relations, and, occasionally, "vice" or something "obscene" and pornographic.
The object and purpose of sexual relations varies with various persons and under various circumstances. In the animal world, the sex urge is the instrument for procreation. Animals fornicate instinctively for that purpose only. Humans do not do so as a rule. Yet the Roman Catholic Church would want just that: sex relations for the same purpose in man as in animals, procreation only. But most individuals seek pleasure in sex or at least seek relief from unpleasant tensions. More and more persons realize that sex serves recreation as well as procreation. But such is rarely admitted and rarely taught in any schools, including medical schools. Sexology as a branch of medicine is still rather widely ignored in formal medical education, to the great disadvantage of the young doctor and his future patients.
For the simple man in the street, there are only two sexes. A person is either male or female, Adam or Eve. With more learning comes more doubt. The more sophisticated realize that every Adam contains elements of Eve and every Eve harbors traces of Adam, physically as well as psychologically.
The better educated person knows of the existence of intersexes, of true and of pseudohermaphrodites in whom the physical sex is in doubt. He is also acquainted with homosexuality, bisexuality, and transvestism, all revealing a disturbed, doubtful, confused, and uncertain manifestation of sex.
Here must be added the picture of the immature sexuality, the sexuality of the child (polymorph perverse, in psychoanalytic terminology), some of which frequently persists into adulthood and then may give rise to homo- and bisexuality, to all kinds of deviations, such as sadomasochism and the often bizarre forms of various fetishisms. Some individuals do "get stuck" in their infantile sexuality.
Aside from such diversity of the expression of the sex urge, there is another more basic multiformity rarely considered except by research scientists, but highly essential for the subject of this book. The reference is to the various kinds of sex that can be identified and separated, in spite of overlapping and interaction.
Ordinarily, the purpose of scientific investigation is to bring more clarity, more light into fields of obscurity. Modern researches, however, delving into "the riddle of sex," have actually produced - so far - more obscurity, more complexity. Instead of the conventional two sexes with their anatomical differences, there may be up to ten or more separate concepts and manifestations of sex and each could be of vital importance to the individual. Here are some of the kinds of sex I have in mind: chromosomal, genetic, anatomical, legal, gonadal, germinal, endocrine (hormonal), psychological and - also - the social sex, usually based on the sex of rearing.
The chromosomal sex, rather loosely equated with the genetic sex, is the fundamental one and is to be considered first. It determines both sex and gender.
At the moment of conception, when fertilization takes place, and when the fathers sperm cell enters the mothers egg, the sex of the future child is decided upon. If the fathers sperm happened to carry a Y chromosome (and approximately half of them do), the fetus will - normally - develop male sex organs and a boy will be born. If it contained an X chromosome, the normal development will provide female sex organs for the fetus, resulting in the birth of a girl.
The mothers egg cell always carries an X chromosome and therefore the normal male chromosomal constellation is XY; the normal female, XX. In rare cases, various imperfectly understood abnormalities may occur and constellations of XXY, XXYY, even to XXXXY, and so on, have been observed with more or less severe defects in the physical as well as the mental structure of the child. Some of these patterns have been aptly described as a "mosaic" of sex. According to recent investigations, it seems that the more severe the chromosomal abnormalities are (for instance, the more X chromosomes are found), the more marked are mental retardation, testicular cell distortion, and genital as well as skeletal disorders.2
The pattern of the sex chromosomes, the so-called sex determinants, remains frozen in every body cell including blood cells. The true sex of an individual can therefore be diagnosed from these cell structures, usually taken for microscopic examination from the skin, the mucous membranes of the mouth, or the blood.
It is not always necessary to make a complete study of the (normally 46) chromosomes (a so-called karyotype) to arrive at the diagnosis of an individuaḷ s true sex. The scientist can also - more simply although less revealingly - look for the so-called sex-chromatin body in the cell structure. If it is found, the individual is female. Males are "chromatin negative." A subdivision of the "chromosomal sex" can therefore be the "chromatin sex."
A great deal has yet to be learned about the genetic sex and until more is known, it may be well to keep an open mind as to the possible causes of some mental abnormalities and sex deviations. At present, they are mostly ascribed to psychological conditioning; but they may yet find an additional explanation in some still obscure genetic fault, perhaps as a predisposing factor for later environmental influences.
Barring accidents during gestation which could bring about hermaphroditic deformities, the newborn boy or girl will reveal the sex through the presence or absence of primary and secondary genital organs. The testes (and the ovaries) are "primary" because they are directly concerned with reproduction. The secondary organs of the male are the penis, scrotum, prostate, masculine hair distribution, a deeper voice, and so on, and a masculine psychology (such as aggressiveness, self assurance, and related traits). All these are further developed and maintained by the testicular hormone called androgen. The secondary female characteristics are the clitoris, vulva, uterus (with its menstrual function), vagina, breasts, a wide pelvis, female voice, female hair distribution, and the usual feminine mental traits (shyness, compliance, emotionalism, and others.)3
Both together, the primary and the secondary sex characters, constitute another, the second "kind of sex," the anatomical (or morphological) sex.
Again a subdivision may be recognized as the genital sex or the gonadal sex, gonad being the collective term for the testes and ovaries.
This genital sex, in everyday thought or language, decides who is a man and who is a woman. The visible sex organs indeed provide the simplest way of differentiation, of which an unwritten law takes advantage. The genital sex in this way becomes another kind of sex: the legal sex, actually not defined in legal codes, yet employed in everyday practice.
In this area, errors of sex can occur and are not too infrequent. The obstetrician or the midwife may be deceived. Usually they take only a quick look at the newborn baby and congratulate the parents on a boy or a girl. But they may have made a mistake. Hermaphroditic or - much more frequently - pseudohermaphroditic deformities may have escaped them, or the organs may be so incompletely developed, "unfinished" (as John Money calls it), or the testes undescended, that the observer was misled. In this way the so-called nursery sex was not the true sex. Consequently the legal sex was wrong too and complications may loom large for the future.
We spoke of the gonadal sex which, however, on closer examination must be divided into two varieties because the gonads have two separate functions. They produce the germ cells and they secrete hormones. And so we have the germinal sex and the endocrine (or hormonal) sex.
The germinal sex serves procreation only. The normal testis produces sperm and where there is sperm, there is maleness. The normal ovary produces eggs (ova) and where they are found, there is femaleness.
But male- or female-ness does not mean masculinity or femininity. These are different concepts, the former referring to "sex" and the latter to "gender." They take in the entire personality. The masculine man and the feminine woman are primarily inherited qualities, but to a large extent they are also the products of the endocrine sex. The abundant supply of androgen in a male would tend to make him more virile, a "he-man," and the rich production of estrogen would insure - at least to some extent - the soft and lovely femininity of the typical woman (I am referring here mainly to physical characteristics. Many psychological ones can be acquired).
The endocrine sex, however, is not linked to the sex glands only. Other glands too supply hormones essential for both sexes to maintain their sex status. Without normal pituitary activity, the endocrine function of the gonads could suffer. Without normal adrenal function, a man is said to lose more of his androgen supply than if be lost his testes, that is, were castrated. This theory, however, based on laboratory work, does not fit the clinical picture and may have to be revised. Just as the anatomical sex is never entirely male or female (one must recall the existence of nipples in men and of a rudimentary penis, the clitoris, in women), so is the endocrine sex "mixed" to an even greater extent. Testes as well as the male adrenals produce small amounts of estrogen. Androgen, in more or less distinct traces, can be found in the ovaries and in larger amounts in the adrenals of females. Their metabolic end-products can be identified and measured in the blood as well as in the urine.
Therefore it can well be said that, actually, we are all "intersexes," anatomically as well as endocrinologically. But we are male or female in the anatomical or endocrine sense, according to the predominant structures or hormones.
The diverse amounts of both sex hormones in both sexes can have their influence on appearance as well as behavior, the appearance, however, largely determined by the genetic constitution, the behavior also by environmental and educational factors.
Consequently, the treatment with hormonal products (or surgical procedures) can make more or less distinct impressions on the endocrine sex, feminizing a male and masculinizing a female. This is an example of how one of the various "kinds of sex" can be deliberately altered. None of them is fixed and unchangeable except the inherited, genetic sex.
Even more flexible than any other is the next and highly important psychological sex. It may be in opposition to all other sexes. Great problems arise for those unfortunate persons in whom this occurs. Their lives are often tragic and the bulk of all the following pages will be filled with the nature of their misfortunes, their symptoms, their fate, and possible salvation.
Many psychiatrists, and especially psychoanalysts, ascribe to early childhood conditioning in an environment unfavorable for a normal healthy development the plight of such patients, who feel that their minds and their souls are "trapped" in the wrong bodies. More will have to be said about this theory. It may suffice to say here that equally unfavorable childhood influences can be traced back in persons who later grew into perfectly normal adulthood with no apparent split between the psychological and the physical sex. Therefore a constitutional factor must be at work (besides the events of childhood) that is a source of the future mental state.
The most striking among these sex-split personalities are the transsexuals. Their problems are intertwined with those of transvestites and also of homosexuals, as we will see in later chapters.
Transsexuals, who want to belong to the opposite sex, and transvestites, who only "cross-dress" in their clothes, sometimes live, quite unrecognized, as members of the sex or gender that is not theirs organically. In these cases, the psychological sex determines the social sex, which otherwise follows the sex of assignment at birth, and the sex of rearing in childhood, both based on the anatomical (and legal) sex. These are normally the kinds of sex in which a person dresses and finds his or her place in the world.
In the vast majority of all people, these latter sexes as well as the psychological sex blend harmoniously with all the other kinds of sex.
To summarize and conclude this introduction: The normal male (normal by his genetic inheritance) has his masculine build and voice, an ample supply of androgen, satisfactory potency, a sperm count that assures fertility, feels himself to be a man, is sexually attracted to women, and would be horrified to wear female clothes or "change his sex." He is often husband and father, works in a job or profession in accord with his sex and gender that is never questioned legally or socially.
The genetically normal female presents the opposite picture. She feels, looks, acts, and functions as a woman, wants to be nothing else, usually marries and has children. She dresses and makes up to be attractive to men and her sex and gender are never doubted either by society or by the law.
Such more or less perfect symphony of the sexes is the rule. Yet, disturbances may occur more often than is usually assumed. Unfortunately, our conventions and our laws have no understanding, no tolerance for those in whom nature or life (nature or nurture) have created a dissonance in their sexuality. Such individuals are frequently condemned and ostracized. Among them we find transsexuals, transvestites, eunuchoids, homosexuals, bisexuals, and other deviates. These latter, however, are not under consideration here.
In rare cases and often against great odds, defying tradition and orthodoxy (not least in the medical profession), some of them, particularly transsexuals, may succeed in "changing their sex" and find a degree of happiness that our present society denies them.
Our sexuality has to be without fault. It must function in strict conformity with customs and laws, no matter how illogical they may be and to how much hypocrisy they may give rise.
Any interference with the sacrosanct stability of our sex is one of the great tabus of our time. Therefore, its violation is strongly resented with emotions likely to run high, even among doctors. Much of this will appear in the chapters that are to follow.