This essay draws from Sandra’s book How the Clinic Made Gender: The Medical History of a Transformative Idea, available now from University of Chicago Press.
GENDER IS HAVING an anxious moment. Several states, including Texas and Florida, have recently introduced laws to restrict or outlaw medical access to gender-affirming procedures. Many states also exclude transgender women athletes from competing on girls’ and women’s sports teams. Others track female athletes’ menstruation, simultaneously policing gender assignment and female reproductive rights. School boards across the country are banning books that feature (or sometimes merely mention) the LGBTQI+ community. Some male politicians have mocked the fact that gender might not match a person’s sex by claiming that they themselves are now women—to great guffaws of laughter among their audience members. Supreme Court Justice Ketanji Brown Jackson was asked to define what “woman” means in her confirmation process and was scorned when she refused to give a seemingly “common sense” answer.
These developments may seem novel, but debating the meaning of gender is hardly new. Nor is deploying so-called common sense to adjudicate such matters. Gender trouble, as the phrase goes, has a history. The meaning of gender and of categories like “woman” have always been historically contingent—and saturated with politics too. To believe otherwise is to ignore the past. Historically, the rights, roles, and privileges of womanhood have been attached to a particular type of woman—white, middle- to upper-class, heterosexual, and so on. Just ask Black suffragists if all women got the right to vote in 1920. The history of the word gender to refer to social sex is admittedly more recent. Perhaps counterintuitively, it was not the feminist movement that made the word. The term was introduced around 1954 in a very specific context: the Johns Hopkins Pediatric Endocrinology Clinic in Baltimore, where it was used as part of the treatment of children born with intersex traits (reproductive or sexual anatomy that does not quite fit our categories of male and female). Intersexuality (or hermaphroditism, an outdated term used at the time) was a problem in search of a solution—and that solution was the idea of gender. The term was meant to denote a sober “scientific” solution rather than being, say, the product of superstition or prejudice or politics. It was seen as a solution that would need to be routinized, and that would then perforce enter the domain of medical expertise.
The clinic “made” gender, in short. But here we need to backtrack. In the late 19th century, sex gonads were understood to determine masculinity and femininity. Physicians claimed that they could easily tell whether someone was female or male based on the appearance of their gonads. Anyone who possessed ovaries was thought to be a woman, no matter their more general appearance or character, and anyone with testes was a man, regardless of how they looked, felt, or behaved. By the 1910s, however, the idea of gonads as agents of sex difference gave way to the concept of sex hormones as chemical messengers of masculinity and femininity. The right decision in assigning sex became more fraught. Practitioners sometimes felt compelled to recommend letting certain patients remain in the sex that they were living in, even if it contradicted their gonadal sex. In the following decades, psychiatrists and psychoanalysts published cases in which a person’s psychological sex did not match their sexual anatomy.
By the 1940s, the situation had gotten more complicated still. Additional sexual variables were now in play. Physicians used what they called the Barr body test as a diagnostic technology for chromosomal sex; they assumed that females usually have one Barr body (i.e., the second inactive X chromosome), while males usually have none. It was far from clear which of these proliferating and sometimes contradictory sex variables—gonadal sex, hormonal sex, chromosomal sex, genitals, internal reproductive structures, and assigned sex/sex of rearing— should determine the individual’s fate, for them to live as either a man or a woman. Which variable could one trust as “true”? What was the right decision for each individual? Physicians worried about cases in which the “wrong” sex had been assigned at birth. If such an “error” in sex assignment was discovered during, say, adolescence, then psychiatrists were apt to point out that some of their wrongly assigned patients had come to fully identify with the sex they had been raised in. A vexing question followed: should these individuals continue living according to their psychological sex or should they be reassigned according to their gonadal or chromosomal signifiers?
Geraldine was just such a case. In 1953, physicians at the University of Pennsylvania Hospital sent the 10-year-old girl and her mother to Lawson Wilkins’s Pediatric Endocrinology Clinic at Baltimore’s Johns Hopkins Hospital, requesting assistance with determining her true sex. She had been raised as a girl, behaved like a girl according to the norms of the time, and when pressed, clearly stated that she wanted to remain a girl. John Money asked her during the psychological interview, “If some blind person came to you and said: ‘Are you a boy or a girl?’ What would you say?” She replied, “I’d know I was part boy. But I wouldn’t tell him.” She would say to this person that she was a girl, she added. Indeed, it had been recently discovered that she had a lone testis. This case history was fairly typical of those invoked at the time in medical debates about intersex traits. It confounded her doctors for the reasons indicated above: What was the true sex variable? What were the consequences of social identity being mismatched to gonadal sex? If the child was reassigned as a boy, what would be the social outcome? Clearly, argued one of the doctors, “only psychologic disaster could follow if this child's gonadal tissues were allowed to determine her eventual sex.” Her mannerisms would, Money added, “create the impression of a very sissified male homosexual.” Neither psychological maladjustment nor homosexuality was a welcome social outcome in the normative 1950s.
At the time, Johns Hopkins pediatric endocrinologist Wilkins, psychologist Money, and psychiatrist Joan Hampson had interviewed 44 patients for their psychological evaluation of patients with intersex traits since starting their study in 1951. Already in the process of preparing their findings for publication, their preliminary conclusions shaped their recommendations at the meeting. What counted for the team at Hopkins was that Geraldine had not only been raised as a girl for the last 10 years, but she also behaved like one. After interviewing, observing, and testing her, Money and Hampson were convinced that she was “psychologically … entirely a girl” and thus should remain as such. Her mannerisms (“posturing, gesturing, position of limbs when sitting and talking, inflection and rhythm of speech”) were feminine. Her testis, Wilkins emphatically said, did not matter. What counted was that her gender role was so deeply imprinted that any reassignment would lead to social and psychological problems.
The team at Hopkins published their findings and recommendations in six articles in consecutive issues of the Bulletin of the Johns Hopkins Hospital in 1955 and 1956. In 1958, when another patient, Charles, was brought to Hopkins at age three, these recommendations were being routinely applied in the Pediatric Endocrinology Clinic. Charles’s physicians had determined that the three-year-old boy had ovaries, an XX sex chromosome pattern, and male-appearing genitals. Charles, the physician told his parents, was a girl. He had a condition called congenital adrenal hyperplasia (CAH). An inborn hyperplasia of the adrenal glands, CAH results in lack of cortisol and overproduction of androgen. In Charles it had caused his genitals to “virilize” in utero and appear male after birth. As Charles had a XX sex chromosome pattern, his local doctor recommended that his sex be officially changed to female. The physicians at Hopkins disagreed. Children like Charles, they argued, learned to be a boy (or a girl) while growing up. Their evaluation of what was by this time about 100 children with intersex traits had shown, they said, that these children most consistently identified with the sex they were raised in, even when, as in the case of Charles, it contradicted their sex chromosomes. Starting in 1954, Money referred to this crucial process of socialization as a child’s “gender role,” which he defined as “all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively.”
But there was a catch: despite the Hopkins team’s insistence on prioritizing gendered expression and socialization over biological sex, the materiality of the body and of its signs, with genitals being the primary ones, still mattered. The Hopkins team believed it was important that a person’s genitals fit their assigned sex. “Fixing” or “surgically reconstructing” genitals thus became a key objective. This meant that any ambiguity in appearance (genital or otherwise) now had to be adjusted to the sex the child was raised in. The body had to be fitted to its gender role, in other words. As a result, in many cases, physicians performed nonconsensual genital surgery, such as clitorectomies and other such “genital corrections.” These surgeries were far from new, but what changed was their volume: they became part of intersex case management (ICM). Whereas previously psychologists and physicians had often listened to children like Geraldine and asked them whether they wanted to be a boy or a girl, now, with the routinization of these recommendations, this was often no longer the case: the recommendations, now solidified into so-called medical expertise, were applied to small children and infants who did not yet have a say in the matter, or indeed a sense of who they were. Those aspects that had previously allowed for self-determination (the older age of patients, and the uncertainty of physicians) thus disappeared. Decades later, intersex activists have rightfully criticized these practices as unnecessary, nonconsensual, and traumatizing surgical interventions.
Gender was malleable, and at the same time it was anything but malleable: it did not allow for diversity outside of a narrow binary. Money and his colleagues firmly believed that children had to be raised within the social norms of being male or female. He and his colleagues may have pushed biological sex off its pedestal, but they insisted on, in accordance with contemporary psychological theories, the social differentiation between boy and girl as pivotal to raising well-adjusted children. This was “common sense.” Proper boys played with cars and were assertive, and girls were meant to be caring, gentle, domestic, and aspiring to marriage. Sexuality was part of this proper gender role development, and heterosexuality was a sign of proper adjustment to one’s gender role. Ironically, a focus on culture and environment could be as deterministic as a focus on biology.
“Gender,” born in the clinic to solve a specific medical problem, soon took on a life of its own. In the late 1960s, the notions of psychological sex and of a learned gender role were reformulated in the field of psychology as “gender identity” and applied in the study and clinical care of transgender individuals. The Gender Identity Clinic, established in 1966 at the Johns Hopkins Hospital at the initiative of John Money, was the first of several university-based “sex change” programs; others were created during the late 1960s and early 1970s at Stanford University, the University of Minnesota, UCLA, and elsewhere. While differentiating between sex, gender role, and core gender identity enabled gender-affirming care, this came at a price. Medical protocols were developed to follow the Hopkins model of binary gender roles and heterosexuality. Trans individuals were pathologized, and offered a narrow definition of gender that often did not reflect their lived experiences.
In the 1970s, “gender” burst out of the clinic. The feminist press took up the word, noting that it was hardly value-neutral, or indeed “scientific.” The contemporary medical understanding of gender roles, feminists pointed out, did not reflect or accommodate the sea change that had been brought to women’s lives by the women’s liberation movement. Feminists used the Hopkins findings to argue that if gender roles were learned, then they could also be unlearned or reconfigured. Women and girls could be boisterous, independent, play with cars, even fall in love with other women and girls, and would still be female. Critical of the normative ideas of masculinity and femininity that underwrote the original concept of gender, some feminists claimed that trans women were letting themselves be turned into tools for reinforcing normative gender stereotypes. Janice Raymond, author of The Transsexual Empire: The Making of the She-Male (1979), for instance, even wrote that “[m]edicalized transsexualism represents only one more aspect of patriarchal hegemony.” The queer community also took up the new term “gender” to give voice to their practices of challenging social roles by purposefully confusing their supposed gender, or, as they more evocatively put it, by enacting “genderfuck” in order to send mixed messages about the very notions of masculinity and femininity and of binary ideas about sex.
“Gender” had gone rogue. A dynamic concept shaped and informed by shifts in American culture and policies, “gender” now, in the 21st century, permeates every aspect of our collective lives. A simple online search of the word produces over 1.1 million results, ranging from gender spectrum, gender unicorn, gender reveal parties, and transgender to the gender inequality index, gender mainstreaming, and gender discrimination. Google’s Ngram Viewer reveals a steady climb in the usage of gender since the 1960s—with a sharp increase from the mid-1980s onward. By the 1980s, the terms gender role and gender identity had become part of the vocabulary of scholars in the social sciences and humanities, and then, a decade or two later, part of the vocabulary of lay people.
Recounting the genealogy of gender matters because it is such a key organizing concept. It is also one that inherently morphs. It is dynamic. It has legs. It is the site of ongoing social and cultural struggle about who owns the word as an idea, who may instill it with meaning, define its implications and judge its importance. We all talk about gender, but we often mean slightly different things. For some, it is just a polite way to say sex, as evident in the surge of gender reveal parties, which are, in reality, just a celebration of whether a child’s genital sex appears to be male or female on a sonogram. Others fear that current theories and practices of gender carry radical implications. Such concerns are expressed in debates about public bathrooms or fears about the destruction of the nuclear heteronormative family. Debates about categories—man, woman, etc.—are debates about meaning and allegedly “common sense” values, and most importantly about rights: Who has the right to be seen? Who has the right to be? Who has control over their own body? Who is legible as a person worthy of respect? The meaning of gender is constantly being remade through medical, social, cultural, economic, and political practices, which broker our rights. What has changed is, in part, our ability to see gender being made and remade—to see the churning process. And what has changed as well is our ability to consciously fill the word with meaning and launch new categories of people into the future.
Sandra Eder, associate professor in the Department of History at UC Berkeley, is the author of How the Clinic Made Gender: The Medical History of a Transformative Idea (2022).