Rachel Snow is a medical student who spent her pre-clinical years at Cambridge University and studied Psychology with Sociology during her third year there. She is now studying hospital-based medicine at Imperial College in London. Rachel has a particular interest in considering gender and how society, with medicine as a subset of society, shapes and forms it.

 Does medicine shape gender or do gender ideals shape medicine?

There are several issues that need to be considered in answering the question. In the first place, we need to decide how we define ‘medicine’. The term ‘medicine’ can cover a broad range of individuals and institutions, many of whom represent different opinions and ideas, so generalising as to what ‘medicine’ as a whole shapes or is shaped by is not easily done.

In addition, and perhaps more importantly, there is the issue of how we identify gender. It is defined biologically either by genital morphology, (the external shape of the genitalia) or by internal reproductive organs known as gonads. It is often these biological determinations of gender, along with associated secondary physical characteristics – men are typically deemed to be taller and more muscular than women – that lead to the assignment of a person’s gender by society. This gender assignment then leads to gendered expectations and the rearing of a person to fit a certain gender role. However, this definition does not always fit. For example, intersex individuals – people whose reproductive or sexual anatomy does not fit the ‘typical’ definition of male or female – may experience conflicting views on their gender if it is defined in this way.

Furthermore, the existence of of transgender individuals leads to issues in this definition of gender based purely on biology, with some suggesting that we instead focus on brain gender. However, this in itself raises other contentious issues, such as how and when brain gender is defined. Cultural expectations of gender roles are therefore important when thinking about how we define gender, and are important to consider when discussing the relationship between medicine and gender ideals. In this essay I will look at the interaction of medicine and gender through time. I will firstly address some of the history of how male and female gender roles became so heavily established and the medical input into these roles. I will then address how advancements in medicine have led to its changing role in shaping gender. Finally, I will discuss the present day situation and potential future changes to medicine and social views on gender definition.

Firstly, when approaching the subject of gender ideals, it is important to look at where cultural ideas of gender have originated. Barbara Ehrenreich (1976) a political activist from the United States, discusses the origins of gender roles and the change that the industrial revolution played in how gender and medicine interacted. In the ‘Old Order’ Ehrenreich argues that society was organised patriarchally at every level of social organisation and belief, not only in the household, but also in the village, church and nation. Despite this patriarchy, women, although subordinate, were not seen as hapless dependents. In fact, their skills and work were seen as indispensable to survival.

However, following industrialisation and the transformation of the market economy into modern capitalism, the roles of both men and women drastically changed. The skills previously commanded by women were less in demand, and instead their role, especially in the upper and middle classes, became that of a refuge for men from the economic climate which was his new quest. This idea, stemming from the sexual romantic movement said that women were there to negate all that went on in the economic man’s world. However, this left little room for women to have their own identities. This can be seen to be where the gender roles of men as the bread-winners and women as the stay-at-home housewives originated. Interestingly, it can also be seen as an example of how gender ideals shaped medicine.

With the idleness that women at home were forced into stemmed many ‘women’s diseases’ such as hysteria, depression and general sickness. This meant that doctors of this age were more focused on treating female specific disorders, and so medicine became more overtly distinguished into medicine for men and medicine for women. Having said this, as I mentioned earlier, one of the primary issues concerning gender classification is the presence of intersex individuals, and it can be seen historically that intersex individuals have been known about for a long time.

With regards to how intersex individuals were treated in society, medicine historically was not the only significant influence, as the Church and the legal system were also prominent and prestigious authorities regarding this matter. However, despite some complex exceptions, since the industrial revolution there have been strongly defined gender roles within society and it is to these  roles of men and women that medicine, and the categorisation of individuals, have been shaped.

Medical advances, and the increase in authority that medicine as an institution gained within society, soon prevented societal gender ideals from shaping medicine. In fact, medicine can now be argued to be the one shaping gender. As the prestige of medicine grew, it also began shaping gender.  Importantly however, medicine chose to shape gender strictly according to the gender ideals that were already in place. That is to say, medicine promoted the distinction of gender into binary groups – male and female. It went about this in several ways, but one of the most prominently studied is the way in which medical advances were used to tackle the issue that intersex individuals posed to the gender categories deemed socially acceptable in the early 20th century.

Ever since medicine was technologically advanced enough to do so, surgeons have been attempting to surgically reconstruct what is controversially known as ‘ambiguous genitalia.’ Some of the research that supports this operation comes from John Money and his work on gender identity in the 1970s. His studies on intersex individuals led him to believe two key principles regarding gender identity. Firstly that individuals are psychosexually neutral at birth, and secondly, that healthy psychosexual development is intimately related to the appearance of gender. His first principle has been largely renounced due to follow up studies on individuals, such as John/Joan, who were gender reassigned and later rejected this gender reassignment. However, Money’s second principle is a key explanation for the surgical reconstruction of genitalia in intersex[ed] individuals or those with ambiguous genitalia. The theory is that they will suffer greater psychosocial problems if this surgery is not performed.

However, this viewpoint and the logic behind the performance of reconstructive surgery has come under much criticism, notably by Alice Dreger. In one of her key arguments she asks, how can we define the the biological norm for gender? The standard of what is considered normal or abnormal is defined by clinicians, and could therefore be seen as arbitrary. Clinicians therefore decide when a child needs to be more clearly assigned into a certain gender. A further controversial decision made by clinicians is which gender a child should be assigned to. Often the decision is made to reconstruct female genitalia, largely because this is a simpler procedure, and because the criteria for a ‘functional vagina’ are not as strict as those for a ‘functional penis.’

In this case, the gender of an individual is shaped simply by the medical capabilities of one individual doctor. This is how surgical advances in medicine have encouraged medicine to attempt to shape gender into distinct binary categories according to the aesthetic outward appearance of biological genitalia. Aside from ‘true hermaphroditism’, where an individual is born with both ovarian and testicular tissue (either in the form of one ovary and one testicle, or an ‘ovotestis’ containing both types of tissue), many individuals deemed ‘intersex’ simply have an abnormally large clitoris or an abnormally small penis. A further consideration to make regarding this idea of surgical reconstruction is that often the parents of intersex children are keen for some decision to be made on gender. Gender distinctions are seen as important from before the beginning of life when early pregnancy scans can determine the likely sex of the child to be born. This is one of the most common pieces of information desired by relatives and friends.

If a child is born and does not fit into one of the two categories, male or female, this would leave the parents feeling lost. Gender identity can be seen as very important when it comes to social interaction or when filling out any sort of official paperwork, and was historically important in the rights the individual had to vote, or to be educated. For this reason there is often pressure from the parents on the medical staff to give their child a gender, which further encourages the attempts of medicine to shape gender. This supposed ‘either or question’ is therefore more complex, as the social construction of gender, and the necessity to be defined as a binary gender in order to access social security causes individuals, even aside from medical practitioners, to shape medicine into shaping gender.

However, the ideals of gender in our society are changing, and many people are trying to fight against the idea of specific gender roles for men and women. In particular, the feminist movement has played an important role in fighting for equality in all areas of life between men and women. This may allow for different definitions of what gender is, and may consider intersex or transgender individuals in such a way that does not require them to fit into a gender category.  Kessler et al (1985) argue that in their utopia we would move away from genitals and focus instead on ‘cultural genitals’, or the way in which a person defines theirself, allowing for a wider assortment between men and women. Others have suggested that gender be seen as more of a continuum, or that gender can be defined on different levels and according to different personality types (Rothblatt, 1995).

These changes in gender ideals have not yet been implemented and it is clear that medicine today has not yet been shaped by these ideals. The institution of medicine is still clearly rooted in shaping gender into two distinct roles. Although medicine has become more accepting of transgender people and the conflict between their brain gender and sexual genitalia, the treatments offered still encourage a transformation from one binary gender to another, rather than allowing for any spectrum of gender identification in the middle. For the moment, therefore, new gender ideals that are becoming more prevalent within society have not yet shaped medicine, and medicine is still attempting to shape gender according to the old gender roles formulated in the 19th century.

In conclusion, this question is obviously more complex than the distinction between medicine influencing gender or gender ideals influencing medicine. They both shape each other, and have both shaped each other in the past. There is also another contributing factor: that of cultural norms, from which gender ideals are formulated. In particular, our appreciation of gender is shaped by the way in which we are brought up, which means that any change in gender ideals is difficult to implement. Indeed, both society and medicine are still strongly rooted in the historic binary division of gender.

That said, this distinction is currently in transition in society. The feminist fight and the attempts to level the societal roles of men and women have created a change that may allow for the binary distinctions of gender to be broken, since gender roles no longer play a role. This could allow different for definitions of gender, such as personality categories, or that of gender as a continuum to be considered. However, gender enforcement beginning before birth is still an issue that requires significant change. Medicine as an institution is highly regarded and respected, and therefore would play a significant role in changing and shaping gender ideals if this were to occur. For those who wish for gender distinction to be dissolved, the problem remains that the practice of medicine is still focused on shaping gender according to historic gender divisions, and this would need to be addressed before gender could be redefined.