Introduction
The term “intersexuality” refers to individuals with atypical biological sexual characteristics, in whom male and female features are mixed to a certain extent. In medicine, the given physiological condition is traditionally defined as a “disorder of sex development,” and such a definition is widely criticized by intersexuals due to its stigmatizing connotation interfering with the recognition of their rights (Curtis 843). From the point of view of intersex individuals, their anatomic peculiarity is neither a medical nor a social pathology – it is a manifestation of biological diversity. The phenomenon of intersexuality was discovered in the middle of the 20th century. The discovery threw down a gage to the traditional dualistic gender system. Therefore, it was regarded as a disease, and like any other disease, it required intervention. Genital surgery became a common method of treatment, although there was not sufficient evidence for its long-term consequences, and positive outcomes were not guaranteed. The medical community decided that growing with atypical genitals will inevitably harm a child’s psychological well-being, and instead preferred to make cosmetic operations because it was considered that gender identity could be imposed on an infant.
Despite the established tradition, recent research findings indicate that gender identity depends on the structure and functions of the brain, as well as the hormonal composition, and has nothing to do with the form of genitals or the fashion of upbringing (Curtis 847). The case of Bruce Reimer may serve as a vivid example of this. On the advice of doctors, the parents of the boy agreed to reassign him as a female and raised him as a girl, Brenda. Later, when the truth was revealed, Brenda/Bruce changed the gender again, but despite the efforts, he committed suicide at the age of thirty-eight. Based on this, it is possible to say that the lives of intersex individuals who undergo surgeries during early childhood may have tragic outcomes. In order to understand the ethical implications associated with surgical fixes in intersex children, we will analyze the issue from the perspective of utilitarianism.
Utilitarian Perspective
Utilitarianism is an ethical theory which suggests that an action or decision may be considered ethical if it leads to the attainment of the greatest possible benefit. There are two major ethical principles: propriety and virtue. In utilitarianism, virtue does not depend on the conformity with the morals and standards of behavior. Therefore, contrary to the deontological perspective in which propriety is a central component, propriety in the utilitarian framework is meant to maximize a known virtue or benefit and minimize suffering (Duwell 70). In the medical discourse, preference utilitarianism is one of the most appropriate approaches to ethical decision making – it aims to maximize the fulfillment of any individual preferences, needs, and interests. From this point of view, the idea of maximization of virtue should be applied to particular circumstances and individual decisions.
According to Mill’s basic principle of utility, an action can be considered ethical when it contributes to happiness, and unethical – when it interferes with the creation of happiness, whereas the benefits for every individual (or the public) involved in a particular case should be considered (Brink par. 2.2). As the case of Bruce Reimer demonstrates, cosmetic surgeries on infants cause greater physical and psychological damage than the developing with atypical genital organs and, therefore, the procedure cannot be regarded as morally justified. The recent evidence makes it clear that the surgical fixes are usually not required from the medical point of view, but these procedures can leave scars and result in incontinence, pain, the loss of sexual sensitivity, and life-long depression (Curtis 845). Intersexual individuals also report such adverse consequences of surgical interventions as discomfort, infections, and unattractive appearance, which frequently require additional treatment throughout life (Curtis 848). It means that surgeries on intersex infants and children do not lead to happiness, it is ethical and fair to leave the right to decide their own gender to intersex individuals themselves.
Since the decisions about the assignment of gender to intersex individuals are made by caregivers, we should analyze the problems related to paternalism. Traditionally, paternalism is defined as “interference with a person’s liberty of action justified by reason referring exclusively to the welfare… of the person being coerced” (Buchanan 15). It means that parents or other authority figures may reduce children’s autonomy when their behaviors or decisions are potentially harmful. The main purpose of paternalism is thus the prevention of mortality and morbidity in children. However, two of the primary criteria for the justification of paternalist attitudes are the necessity, and the least infringement (Buchanan 16). When considering the mentioned above evidence on risks for multiple harmful effects of surgeries on intersex individuals, we may conclude that parental decisions to assign infants to a particular gender do not meet these two criteria and the major purposes of paternalism. Moreover, it is important to consider the possibility that parents may be largely motivated by personal beliefs, values, and preferences. In this way, caregivers’ decisions may be primarily oriented towards the fulfillment of their own interests rather than the best interests of their children. Therefore, although an early gender assignment may be beneficial for parents concerning their psychological satisfaction, it contradicts the ethical principle of utility because the procedure does not imply equal chances for living a happy life and provokes the risk of significant harm to intersexual individuals.
Deontological Perspective
Contrary to utilitarianism, deontology, also known as the ethics of duty, suggests that the propriety of actions directly depends on the quality of those actions (Duwell 43). It means that a decision can be considered ethical only if it conforms to common rules, standards, and principles associated with professional duty. The righteousness of action is thus determined by the type of action rather than its consequences, no matter how adverse they may be. When applied to resolve the intersex dilemma, deontology seems to justify the hospitals’ encouragement of surgeries because it meets the current medical standards and views on intersexuality as a disorder.
Deontologists believe in the superiority of various moral obligations defined by relationships between people and different social agents (e.g., doctor-patient, parent-child, etc.). Thus, from the given point of view, parental decision-making and reduced autonomy of children are justified because it is considered that parents know better what is good for their children, and it is better to allow them to take timely actions rather than wait for an intersex individual to mature. In a similar way, deontology justifies doctors’ promotion of surgical interventions if they explain all potential risks and benefits of the procedure and its alternatives to the patients or caregivers. But an important criterion is that, when doing so, doctors should not seek approval and personal benefits but should merely fulfill professional duty. In this way, from the deontological perspective, gender reassignment initiated by parents or healthcare providers can be regarded as moral and rational as they follow the universal norms of behavior.
Virtue Ethics
According to Aristotelian ethics, all human actions aim to achieve certain goals that serve to fulfill the ultimate purpose of life – happiness (Duwell 40). However, every individual has own understanding of happiness, and the ultimate virtue can be attained only through the activity which manifests all peculiar interests and preferences of a human being. Ethical virtue is the virtue produced through reasoning, i.e., a practical activity aimed at individual self-realization and happiness.
From the perspective of virtue ethics, when we deprive a person of a right to live according to own nature and impose a particular gender identity on him or her, we act unethically because we deprive this individual of an opportunity to become truly happy. The involuntary gender assignment can be especially harmful when the fact of an administered surgical intervention is hidden from a child (e.g., parents may say that the scar is left from hernia removal, etc.) As a result, an intersexed person suppresses his or her natural instincts in order to fit in the social order and meet public expectations. Such a situation is extremely detrimental to individual psychological health and may have irreversible adverse impacts. Therefore, virtue ethics suggests that intersex children should make decisions regarding their gender autonomously and independently of parental or hospitals’ influence because, in this way, they will be able to generate virtues, interact with other individuals in a productive and mutually beneficial way, and enhance self-esteem.
Conclusion
The interests of every child include the preservation and expression of their own natural identity, right to choose appearance and avoid unnecessary surgical interventions. Moreover, as the analysis revealed, although parents have a legal power to decide the medical issues pertaining to the health of their children, children and caregivers may have competing interests. Parents may be insufficiently competent to choose the gender of an intersex individual, may neglect his or her rights, and pursue other personal interests such as the convenience of upbringing or the maintenance of a habitual way of interactions with the society. By evaluating the given factors from the utilitarian perspective, we come to a conclusion that a child should not be imposed with gender identity and should be allowed to express his or her natural identity. The autonomous decision-making of intersex children meets the ethical principle of utility because it provides an opportunity to maximize chances for happiness and avoid substantial harm to the involved parties.
Annotated Bibliography
Brink, David. Mill’s Moral and Political Philosophy. Stanford Encyclopedia of Philosophy, 2014.
In this comprehensive encyclopedia entry, Brink reviews the life and work of a prominent English philosopher of the 19th century, John Stuart Mill. As a utilitarian philosopher, he substantially contributed to the development of ethics. In my research, I mainly focus on the principle of utility introduced and evaluated by Mill. In his teaching, ethical utility equals the greatest happiness. This principle implies that “actions are right in proportion as they tend to promote happiness” (par. 2.2). Brink also reviews such important philosophical and theoretical aspects of utilitarianism as the proof of utility (i.e., justification criteria), and the sanctions of utility (i.e., human motivations). This information is important in my research because it serves as the theoretical framework for the analysis of intersex dilemma.
Buchanan, David R. “Autonomy, Paternalism, and Justice: Ethical Priorities in Public Health.”American Journal of Public Health, vol. 98, no. 1, 2008, pp. 15–21.
In the article, Buchanan reviews and investigates the ethical and legal issues associated with paternalism in medical decision making. The concept refers to the restriction of individual autonomy by caregivers or other authority figures in order to improve health and minimize negative outcomes. The article is of great interest for me because the author pays attention to the investigation of the limits of paternalism. The restriction of intersex children’s liberty, their reduced autonomy, and inability to consent for the operation provoke significant ethical concerns as the power to assign gender is wholly given to parents who may harm a child by their decision. Buchanan evaluates the criteria and factors which justify paternalistic behaviors, e.g., imminent threat of illness, necessity, etc. and this evidence can be generalized to the intersex dilemma and largely supports the evaluation of ethical implications related to involuntary gender assignment.
Curtis, Skylar. “Reproductive Organs and Differences of Sex Development: The Constitutional Issues Created by the Surgical Treatment of Intersex Children.”Mcgeorge Law Review, vol. 42, no. 4, 2011, pp. 841-872.
The article is devoted to the legal, ethical, and medical issues associated with intersexuality and intervention procedures. Curtis provides a historical overview of the problem and evaluates the theoretical presumptions introduced by Dr. John Money in his “John/Joan” case study. However misleading his ideas were, they represent the foundation for the traditional medical approach to intersexuality and, although the recent findings demonstrate that gender identity cannot be imposed through upbringing, the current methodology has not substantially changed so far. The given research is directly linked to the theme of my study. Curtis’s findings allowed me to build greater awareness of the problem of intersex surgeries and deepen the analysis.
Duwell, Martin.Bioethics: Methods, Theories, Domains. Taylor & Francis, 2014.
In the book, Duwell provides a comprehensive review of ethical theories pertaining to bioethics and medical decision making. The book is a rich source of information on fundamentals, principles, standards, and applications of various theoretical approaches in medicine. When reviewing all the philosophical and ethical concepts, Duwell emphasizes the importance of an interdisciplinary approach to bioethical reflection and its significance for the improvement of clinical practice. Since my research implies the ethical evaluation of a practical problem, the source was very useful. I mainly used it to retrieve the information on the required normative ethical models. It guided me throughout the analysis of the intersex dilemma.
Works Cited
Brink, David. Mill’s Moral and Political Philosophy. Stanford Encyclopedia of Philosophy, 2014.
Buchanan, David R. “Autonomy, Paternalism, and Justice: Ethical Priorities in Public Health.” American Journal of Public Health, vol. 98, no. 1, 2008, pp. 15–21.
Curtis, Skylar. “Reproductive Organs and Differences of Sex Development: The Constitutional Issues Created by the Surgical Treatment of Intersex Children.” Mcgeorge Law Review, vol. 42, no. 4, 2011, pp. 841-872.
Duwell, Martin. Bioethics: Methods, Theories, Domains. Taylor & Francis, 2014.