Queering the Moment of Hypospadias "Repair"
Heteronormativity structures biomedical justifications for continuing surgical interventions on infants' genitals that are cosmetic and medically unnecessary. It would seem, then, that queer theory is uniquely suited to challenge this continuing practice. This article takes up the question of what queer theory can do for intersex, with particular focus on queer temporality. I consider the example of "hypospadias repair," a surgical intervention justified by invoking restrictive norms of what the penis should look like and be able to do at some point in the future. In contrast, intersex activists invoke post-medical futures, structured by norms of consent and bodily integrity. While queer approaches to temporality might challenge the notion of intervening surgically on an infant for the sake of the future adult the child will become, might this queer critique also disrupt the ability of activist individuals and organizations to invoke other narratives of the future, including ones where adults have not had irreversible surgeries as infants? I will ask whether queer theories of temporality and futurity can challenge medical practices that compromise consent and bodily integrity. Can queer theory question surgery as a queer moment and help us to conceptualize all bodily differences within a more expansive frame, without reinstating heteronormative narratives of futurity?
intersex, hypospadias, queer theory, temporality, queer time, surgery
In 2009 Iain Morland (2009c) asked: "What can queer theory do for intersex?" Central to his question was the sense that intersex should not bear the responsibility of confirming or challenging social theories of sex, gender, and sexuality; rather, scholarly tools should be brought to bear on ethical and practical issues raised by intersex. Morland concluded that queer theory can "do" things for inter-sex, although focus must be shifted from queer theory's traditional emphasis on pleasure and touching, especially as genital surgery often leads to a reduction of tactility or sensation. Intersex scholars and activists (these terms are not mutually exclusive) since the 1990s have seen the potential for queer theory with regard to critiquing the medical "management" of intersex (Holmes 1994). While early scholarly work was important for the formation of intersex rights organizations (Kessler 1990; Fausto-Sterling 1993), there has been justified criticism by intersex scholars and activists of the fact that scholars often used intersex to further academic arguments rather than to bring academic concern and focus to the issues that actual intersex people face. As the intersex activist Emi Koyama (2003: 4) stated, work in the social sciences and humanities often used "the subject of inter-sex as a gender issue, and a way to illustrate the social construction of gender, without explicitly addressing medical ethics or other issues with direct real-life implication to the lives of intersex people."
The 1990s and 2000s saw significant publications on intersex and sexuality studies by both activists and scholars (Fausto-Sterling 1993; Chase 1998; Kessler 1998; Dreger 1999; Preves 2003; Mak 2005; Holmes 2008). However, in 2005 US-based medical professionals recommended moving away from the language of intersex (and hermaphroditism) to the new classification system of disorders of sex development (DSD). This move has been widely accepted in the medical [End Page 499] community despite a lack of clarity about which bodily variations are included within this scheme (Griffiths 2018b). Many intersex individuals and communities, however, criticized, questioned, or rejected this change. For many, "intersex" framed variations of sex characteristics as a social issue and allowed communities to be forged around intersex as an identity, lived experience, or political rallying cry. For these critics, DSD represented a reestablishment of medical authority over bodies with variations in sex characteristics and justified surgical and/or hormonal intervention at the expense of consideration of issues such as bodily integrity, consent, and psychological support (Davis 2015). While some scholarly work has recognized the potential of moving beyond "disorders of sex development" to "variations," "divergences," or "differences" of sex development (Reis 2007), work in the humanities and social sciences mainly continues to use the language of intersex. In 2009, Morgan Holmes once again reaffirmed the links between intersex and queer theory, in Critical Intersex.
Despite Holmes's intervention and Morland's provocation, however, queer theory has not substantially taken up the question of what it can do for intersex, or for variations of sex characteristics like hypospadias.1 Hypospadias is where the "urethral meatus," or "pee-hole," appears not exactly at the tip of the penis. The urethral meatus may appear just underneath the glans of the penis, on the underside of the shaft, in the scrotum, or near the perineum. Hypospadias is thought to affect roughly one in three hundred infants assigned male and can appear with other symptoms or on its own, and with varying degrees of "severity" (van der Horst and de Wall 2017). The recommended treatment is generally surgery, often before the child is eighteen months old. Research suggests that hypospadias "repair" is by far the most common surgical intervention on infant's genitals; despite decades of criticism from activists and scholars, roughly two thousand surgeries happen in the United Kingdom on the National Health Service every year (Monro et al. 2017). In fact, intersex scholar Katrina Karkazis (2008: 144) has described hypospadias surgeries as the "bread and butter" work of pediatric urologists. While surgeons often promise successful treatments with no complications, narratives from individuals who have undergone surgery often tell a different story, reporting multiple follow-up surgeries due to complications. Katrina Roen and Peter Hegarty (2018), in a review of the medical literature concerned with follow-up, concluded that complications were considerable and more common in proximal hypospadias (where the meatus is farther from the tip of the penis). Significantly, they question whether these statistics are well-known by medical professionals or communicated to parents when they are facing a decision about whether to "repair" their child's hypospadias. [End Page 500]
Hypospadias "repair" seems to be relentlessly future-oriented in the surgical imagination. Activism too is focused on ending surgeries for the sake of a better future. A queer critique of futurity might then challenge both approaches to bodily difference. I will argue, however, that in practice the seemingly future-oriented surgical intervention is always a unique moment that shuts down more possibilities than it opens up. In this article I will ask what queer theory can do for hypospadias and for medicalized bodily differences more broadly. Following an introduction to Holmes's and Morland's work, I will lay out four competing ways of thinking about hypospadias: as a bodily anomaly; as a sign of a DSD; as something "normal" men can have unknowingly; and as a bodily variation. While these conceptualizations are different, they share common ground in a recognition that bodies are different from each other and that surgery is guided by certain norms. A focus on these norms as temporal will lead to a discussion on queer theory and temporality.2 I will argue that the strategic futurity of intersex activism opens up possible futures—futures that include accountability and responsibility. This approach queers the moment of hypospadias "repair," reframing the supposed choice between "doing something" (surgery) and "doing nothing" (waiting). I suggest that doing something can be a foreclosing of promise and potential, while waiting is not the same as doing nothing and opens up new horizons of possibility.
Queer Theory and Intersex: Morgan Holmes and Iain Morland
Holmes (2006) credits two events as integral to a shift in the early 1990s in the popular awareness of intersex: Anne Fausto-Sterling's article "The Five Sexes" (1993) and the founding of the Intersex Society of North America (ISNA). Holmes was an early member of ISNA and in 1994 linked Fausto-Sterling's research with ISNA's activist agenda, her own personal experience, and the critical language of queer theory. She argued at that time that "little has been written about intersexuality, although its concerns often intersect with those of feminist and queer theory" (Holmes 1994b: 11). Throughout her work she has argued that the surgeries that aimed to "normalize" her body at a young age did nothing of the sort, declaring in 1994: "I'm still intersexual." In fact, she has argued that "standard treatments actually render many patients more intersexed following surgical intervention" (Holmes 2002: 174). For Holmes, intersex surgeries fail on their own logic as they fail to normalize bodies; however, they continue through a discursive reliance on a narrative of promised future heterosexual, binary-gendered normality (2008). This is not the only narrative available, however, and Holmes (1997/8: 9) argues that parents and doctors must "give up ownership of the sexual futures of minors" so [End Page 501] as to allow for a wider range of potential possibilities: "The promise is not for the medical profession to make. 'Sexual normalcy' is up to each individual to create for him/herself" (9).
Morland has also analyzed intersex surgeries in terms of narrative and discourse. For Morland, genitals can be understood as textual signifiers; at the moment of birth, the infant's genitals are expected to signify within a binary system, "readable" as either male or female. He argues that these genital signifiers do not refer to "real" genitals. Instead, they refer to a set of social and medical standards: "This isn't a question of having a penis; it's a question of having a genital that means 'penis', and so is a penis, when judged by the phallic standard of size" (2004: 450). He further argues that infant genital surgery is "hyperbolic" (2005: 339), based on a fantasy of "the endlessly enormous penises, the measurelessly capacious vaginas, the infinitely dainty clitorises upon which surgeons model their patients' genitals" (2001a: 365). These are imaginary nostalgic fantasies of genitals that were never really real in the first place (2001a; see Garber 1999). This tension between imaginary and real genitals is significant here. Morland (2005: 339) has argued that the language of hypospadias "repair"—of restoration and reconstruction—"misdescribes procedures that are at best constructive . . . and at worst injurious. . . . In the case of hypospadias, the patient has never had a urethra running to their glans, so there is literally nothing to reconstruct." Morland's work draws attention to the slippage between imagined representational future genitals and the real fleshy genitals of the intersex child. In this example, the real (no urethra running to the glans) is disregarded in favour of a future representative penis (with a urethra running to the glans), a nostalgic ideal penis, conceptualized as a future penis that the surgeon can bring into existence.
Both Holmes's and Morland's 2009 publications engaged with temporality. Holmes's introduction to Critical Intersex is titled "Straddling Past, Present, and Future." Similarly, Morland's introduction to the GLQ special issue Intersex and After (2009b: 191) noted that "the history of intersex treatment, which now includes the recent history of its ethical critique, is marked by a curiously disjointed temporality." If Critical Intersex attempted to "compel" intersex studies "forward" (5), the essays in Intersex and After engaged with "the peculiar 'afterwardsness' of intersex and its many lessons" (192). Both publications were deliberately multi- or interdisciplinary. For Morland, the medical management of intersex has emerged from a multiplicity of disciplinary contexts, and while "such contexts have made medical protocols obdurate, they have also left intersex treatment open to critique from multiple disciplines" (195). Multiple disciplines are required to critique intersex, but within a queer framework, these disciplines must also critique [End Page 502] their own role in intersex studies: what exactly can they do for intersex? Holmes concluded her Critical Intersex introduction by linking this reflexive critique with temporality, arguing that "historical, activist, and theoretical work on human intersexuality has reached a point where, in order to mature, it needs to critique its own dominant paradigms" (11). Since the 1990s, intersex scholars and activists have been challenging the dominant medical narrative, suggesting new narratives wherein intersex is considered a bodily difference and a social issue, not a medical emergency that prompts early surgery. In these narratives, intersex genitals are signifiers of difference, not disorder. However, both Holmes and Morland retain a critical perspective on both the medical and social narratives. Morland in particular critiques the idea that the narratives of humanism (2007), postmodernism (2006), or the reforming nature of critique (2009a) will necessarily improve standards of care for intersex individuals.
Competing Significations of Hypospadias
In the previous section I outlined the work of Morland and Holmes as intersex scholars who have written extensively on intersex, queer theory, and their own personal experiences. I will now set out four competing ways of thinking about the materiality of hypospadias: as an anomaly; as a sign of a DSD; as something "normal" men can have unknowingly; and as a natural bodily variation.
An Anomaly
In the field of pediatric urology, hypospadias is generally considered an individual anatomical feature that may or may not lead to a diagnosis of a DSD. In the eleventh edition of the Campbell-Walsh Urology textbook (2015), hypospadias is defined as follows:
Hypospadias refers to a urethral opening proximal to the normal glanular location. The defect is commonly considered arrested development, even though embryo penises do not exhibit a similar-appearing phase. Correction is surgical and includes not only urethroplasty but also straightening ventral penile curvature, circumcision or prepucioplasty, and scrotoplasty with the goal to restore as normal function and appearance as possible.
(Snodgrass and Bush 2015: 3399)
It is clear from this passage that hypospadias challenges both bodily and temporal norms and that the role of surgery is to reinstate these norms. The passage [End Page 503] encourages the reader to think of hypospadias as arrested development, but it also insists that it is not. It defines the variation as a defect, for which correction is simply surgical, to "restore" a norm. The fact that a penis with hypospadias is described as arrested development, or "unfinished," despite no similar phase in embryo, underscores Morland's arguments that this is about signification and nostalgia rather than "real" genital standards. It also emphasizes the centrality of a normative timeline in these surgical interventions, a point to which I will return.
A Sign (Along with Other Symptoms) of a DSD
Warren Snodgrass and Nicol Bush (2015: 3399) argue that "90 percent of hypospadias cases are isolated penile defects." For this reason, they do not classify hypospadias as a DSD. Elsewhere I have argued that to be classified within the DSD system is to be named in a system grounded in promissory genetics, predicated on the belief that future developments in genetic science will necessarily "sort out" the messiness of bodily variation (Griffiths 2018b). Other scholars have pointed out that the DSD system relies upon the biological determinism of brain organization theories, repackages heterosexist and cisgenderist assumptions (Clune-Taylor 2019), and reifies medical authority and the pathologizing of natural variations (Davis 2015). The suggestion of a nomenclature change to "disorders of sexual differentiation" was raised in a meeting of medical professionals with only two intersex people present in Chicago in 2005 (Dreger, Chase, and Sousa 2005; see also Feder 2014). The "Consensus Statement on Management of Intersex Disorders" (Hughes et al. 2006: 554) was published the following year and defined DSDs as "congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical." As an anomaly, it is not clear at first glance why hypospadias would not be classified as a DSD. However, the definition of DSD is that of "conditions in which . . . anatomical sex is atypical." Hypospadias falls out of the DSD classification system as an isolated "anomaly" and therefore not a "condition." Hypospadias retains its significatory potential outside this classification system, however, as a marker of possible DSD if accompanied by other "symptoms" (such as undescended testes).
Something "Normal" Men Can Have "Unknowingly"
Jan Fitchner and colleagues (1995) studied the penises of five hundred men who had not previously undergone hypospadias surgery, who were admitted to the hospital for other treatments. The location of the meatus in relation to the tip of the glans was measured, and each individual answered a series of questions about their penises and their sexual life. The study found significant variation in the [End Page 504] location of the meatus in these men (aged thirty-eight to seventy-five years), none of whom had a diagnosis of hypospadias. They all reported sexual intercourse without problems—the report states that of the men classed as hypospadiac based on cosmetic appearance, "all except one homosexual patient have fathered children" (833). They conclude: "An operation designed only for improved cosmesis becomes questionable when 45% of our investigated adult patients do not have the meatus at the tip of the glans, which is the desired location in all current surgical techniques" (834). Peter R. Dodds and colleagues (2008) conducted a study over two years, during which time urologists identified patients over the age of eighteen with "easily recognizable hypospadias" (682). Only one of the fifty-six participants had a complaint related to their hypospadias. In fact, eighteen of the fifty-six (32%) "stated that they were not aware they had an abnormality of the penis. . . . Another 6 patients (11%) stated that they were only aware of their hypospadias because a physician or nurse had pointed out the abnormality to them" (683). We might say, then, that 43 percent of participants did not consider their penis (now diagnosed as hypospadiac) as anything but normal until informed otherwise by medical professionals.
These studies demonstrate that the attitudes of medical professionals and nonprofessionals differ significantly as to what constitutes normal cosmetic appearance. As Holmes (2002) and Morland (2009c) have both stressed, the cosmetic appearance deemed "good enough" by doctors did not "normalize" their bodies. These studies also support Morland's claim that surgical standards do not correspond to "real" penises but to fantasies of penises that are at once nostalgic and future-oriented. These studies and others suggest that while urologists are the arbiters of penis aesthetics in the context of hypospadias, they are working with stricter norms of what a penis should look like and what constitutes a normal penis. Indeed, if populations of men with "undiagnosed hypospadias" are no more or less anxious about their penises than those deemed "normal," to what extent can we expect surgical intervention to be the right tool for the job here?
A Bodily Variation
While the DSD classification system was quickly and widely adopted in the medical community, many intersex individuals and groups have criticized and refused the shift away from the terminology of intersex (Lundberg, Hegarty, and Roen 2018). As part of a critical response to the DSD terminology, intersex scholar and activist Miriam van der Have (2017) suggested a shift in the very definition of the term intersex. This "post-medicine definition" defines intersex as "the lived experience of the socio-cultural consequences of being born with a body that does not [End Page 505] fit with normative social constructions of male and female." This moves the focus from individual bodily differences (whether at the level of individual features such as hypospadias or groupings of "symptoms" into "conditions") to the social context in which such classifications are made and the consequences (including medical) of this. Using this definition, hypospadias may well seem to fit as intersex. Certainly, adults speak of significant negative consequences following the identification of a penis that does not fit the normative constructions of what a penis is in terms of function and aesthetics.
Imposing Penis Norms
Common to all these four definitions of hypospadias is the idea that bodies are different from each other. However, it is clear that defining hypospadias as a defect or disorder might lead to surgical intervention to bring the penis in line with norms of function and appearance, while seeing hypospadias as a natural variation might lead to questioning these norms. Roger Mieusset and Michel Soulié (2005: 163) outlined the three norms that drive surgical interventions on penises deemed by medical professionals to have hypospadias: "to 1) enable voiding in a standing position, 2) allow a normal sexual life, and 3) obtain a penis with as 'normal' a cosmetic appearance as possible." These are the norms that have historically driven this surgical practice. Recent research interviewing clinicians in England, Scotland, and Sweden demonstrates that these three norms are still very much in play (Roen and Hegarty 2018). I have already discussed the aesthetic norms that drive surgery. In this section I will consider the first two of Mieusset and Soulié's three norms in more detail before considering how they construct normative temporalities. Specifically, I will draw attention to the fact that these norms consider the infants' genitals not as they are but as they are imagined to be at some point in the future.
First, consider the drive to enable voiding in a standing position. The association of peeing standing up with a successful performance of masculinity has a long history. Geertje Mak's (2012) research has revealed that throughout the nineteenth century, whether an individual of "doubtful sex" could urinate standing up was one of the strongest factors in the medical and legal decision that would determine to which "social sex" the individual belonged. In Mak's research, peeing standing up was a performance that inscribed the individual as a man in society. This was an external inscription, but in the twentieth century, this turned inward. In 1951, Thomas Twistington Higgins, Denis Frederic Ellison Nash, and David Innes Williams (1951: 219) argued: "It is generally recognized that restoration of [End Page 506] normal masculine micturition must, if possible, be achieved before the school age, say 5 to 8 years. For psychological reasons it is obviously important that the boy at school should pass urine like his fellows"
While in Mak's nineteenth-century examples peeing standing up is important for social inscription, in the twentieth century it is increasingly tied to a notion of a sexed psychology (however vaguely defined). By the late 1960s, peeing standing up takes on another dimension, expressed in the language of "rights." Urologists O. S. Culp and J. W. McRoberts stated in 1968 (312; emphasis added) that "it is the inalienable right of every boy to be a 'pointer' instead of a 'sitter' by the time he starts school." They even go so far as to say that "it is the basic right and privilege of every hypospadiac to be able to write his name in the snow and have it legible. Anything short of this is undesirable" (315). Peeing standing up is a penis performance that is both external (inscribing the individual as male in society) and internal (supposed to serve as a way of cohering the body with the inner gendered "psychology" and supporting "psychological development"). By the second half of the twentieth century, it is also tied to emerging ideas about the rights of the child. However, in the kinds of human rights that are mobilized in 1968, it is clear that rights are predicated on gender normativity, and the rights of the infant are subordinated to the rights of the older child or adult to come.
Recent research suggests that medical professionals working with infant hypospadias are not entirely convinced of the importance of peeing standing up. While some, when interviewed, insist that a boy must be able to "stand up at the urinal with his pals and pee in the pot at the same time," and thus surgeons should try to "sort this out early in life," others question this logic, arguing that "children these days do not look at other people's, other children's penises, they just don't do that," and therefore, "I'm not sure whether it's medically essential" (Hegarty et al. 2021). Some men with hypospadias do speak of anxiety surrounding urinating standing up at the urinal (Kerry 2014). However, urinal anxiety is not limited to individuals with hypospadias (Haslam 2012). Sheila Cavanagh (2010), for example, has collected experiences of lesbian, gay, bisexual, trans, and/or inter-sex individuals who speak of urinal anxiety. Peeing standing up complexly signals masculinity and norms of heterosexuality; it therefore seems something of a tall order to expect that surgeons can "sort this out early in life" (see Griffiths 2020).
The second norm that is said to drive surgery is that of its facilitating a "normal sexual life." Research since the 1990s has underscored the heteronormativity inherent in this kind of justification and measure of success. Suzanne Kessler (1990: 19) made clear the compulsory heterosexuality that structured decision making and measures of success following surgery: "The ultimate proof to these [End Page 507] physicians that they intervened appropriately and gave the intersexed infant the correct gender assignment is that the reconstructed genitals look normal and function normally once the patient reaches adulthood. The vulva, labia, and clitoris should appear ordinary to the woman and her partner(s), and the vagina should be able to receive a normal-sized penis." Missing from this logic is any sense of sensitivity or pleasure. Perhaps unsurprisingly, a "normal" sexual life continues to be heteronormatively framed, just as Kessler described in 1990. In hypospadias surgery, sexual stimulation, feeling, and pleasure are subordinate to the ability of the penis to penetrate (a vagina) and shoot semen in a strong direct stream. Snodgrass and colleagues (2011) admitted that "glans sensitivity" is mostly ignored in urological discussions of hypospadias (154). Once again, the imposition of an external norm of penis function and aesthetics is considered more important than any individual's pleasure or satisfaction with their penis. This is a central theme of intersex critique. Holmes (1994) has spoken of the pleasures she could have enjoyed with her "phalloclit" had it not been surgically altered to fit an external norm of appropriate clitoris length.
Penises of the Future
Hypospadias surgeries are driven by three norms: peeing standing up, heterosexual sex, and cosmetic appearance. These norms have been questioned by scholars and medical professionals as well as challenged by critical studies. Despite this, surgeries continue. Medical texts generally recommend that hypospadias "repair" occur at between six and eighteen months of age (van der Horst and de Wall 2017). Therefore, the three norms of urination, sexual intercourse, and cosmetic appearance actually refer to surgical imaginings of what a normal penis should look like, be able to do, and how, at some point in the future. Justifications for hypospadias surgery seem to be relentlessly future-oriented; while surgery is on the penis of a child, it is for the supposed benefit of the adult and the adult penis that they will supposedly want. At the same time, following Morland, we can see this future penis as "nostalgic" and somehow backward looking. This is not necessarily a contradiction. As Sara Ahmed (2010: 160) explains, "Nostalgic and promissory forms of happiness belong under the same horizon, insofar as they can imagine happiness as being somewhere other than where we are in the present." The aims of hypospadias surgeries are both nostalgic and promissory, promising a perfectly normal future penis, based on nostalgic penis fantasies in the surgical imagination.
Intersex scholar and activist Cary Gabriel Costello (2013) argues that discussions [End Page 508] of hypospadias in medical texts differ from discussions of other genital variations. He compares hypospadias classification diagrams in medical texts to Prader and Quigley scales. The Prader scale was devised in 1954 to illustrate genital variance among individuals diagnosed with Congenital Adrenal Hyperplasia (CAH) (Prader 1954). The scale illustrates five stages, I–V, of "virilisation" of female genitalia, with stages 0 and VI representing "normal female" and "normal male," respectively (Karkazis 2008: 307–8). Stages I–V represent possible genital appearance between these two possibilities, which are coded as "opposites." Yosef Gavriel Levi Ansara (2013: 112) has noted that the depiction of a spectrum of possibilities could threaten binary thinking about biological sex; however, cisgenderism and binary thinking necessarily figure stages 0 and VI as normal and opposite and stages I–V as pathological: "Prader Stage V, which is considered the most 'extreme' stage of infant genital virilisation, is viewed as the most severely pathological precisely because of its visual and structural similarity to Prader's 'Normal Male.' Thus the historically recent 'two-sex' model . . . is reinforced by the practice of pathologising genital similarities between female and male genitals." The Quigley (Quigley et al. 1995) scale was designed in 1995 as a representation of a grading scheme for the clinical classification of Androgen Insensitivity Syndrome (AIS). Similar to the Prader scale, a spectrum of possibilities is framed as two oppositional sexed norms with pathological intermediate stages. Nevertheless, these scales do depict a spectrum of genital possibilities. By contrast, Costello (2013) has argued that medical illustrations of hypospadias show something "odd": "A carefully illustrated 'normal penis' with a series of dots superimposed upon it to indicate the level at which the urinal meatus / vaginal opening are located. The penis is always illustrated as erect, and often with a lot of illustrative detail to emphasize the 'reality' of this imaginary ideal penis existing instead of the intermediate genitals actually present." While the Prader and Quigley scales show intermediate stages, illustrations of hypospadiac penises show just one penis, with a series of dots to illustrate the possible location of the meatus. The illustrations seem to carry the message that while hypospadias may be a "defect," this does not make the penis any less a penis.
As Costello (2013) argues, it is unlikely that penises with proximal or perineal hypospadias will look like these illustrations. The diagram serves not as a representation of what the child, parent or surgeon will see but as an imaginary future penis—large, straight, and "normal"—with an "anomaly" that is correctable by the surgeon. The infant's penis is not a thing in its own right but rather a placeholder or undeveloped version of something to come: "Parents (and doctors!) must be reassured by looking at the erect, large, ideal penises drawn in the hypospadias [End Page 509] illustrations that the genitally intermediate flesh of the child they see is illusory, and that an excellent penis will soon be revealed by the scalpel."
The infant penis is seen as illusory and intermediate while the imaginary penis that the surgeon hopes to bring into existence is ironically considered more real. This logic was seen earlier in the passage from Campbell-Walsh Urology in which hypospadias are conceptualized as arrested development, even though this is undermined by embryological development. It is also reflected in the fact that intersex genitals are often referred to as "unfinished" (Morland 2001b, 2005). Intersex bodies in a medical framework are always "temporally disordered" (Danon 2018: 90), with interventions designed to retrieve bodies into more normative timelines (Grabham 2012).
Infant genitals are illusory, and nostalgic-promissory genitals are treated as the "real" development goal of all bodies. The goal of infant surgeries on infants with variations of sex characteristics is to secure what Catherine Clune-Taylor calls "cisgendered futures" (2019). That the future adult penis is treated as more "real" and worthy of protection than the infant's existing genitals is an important bioethical point. A bioethics paper in 2010 drew attention to the fact that there are ethical imperatives toward the child as well as to the adult that the child will become (Wiesemann et al. 2010). This prompts a reconsideration of logics that suggest doing surgery early is better for the future adult, as there is an ethical responsibility to the future adult to have been involved in and informed about decisions made about their body as a child.
Activism and Postmedical Futures
In 1998, Cheryl Chase (189) argued that intersex people began in the 1990s to transform "intensely personal experiences of violation into collective opposition to the medical regulation of bodies that queer the foundations of heteronormative identifications and desires." Unexpected variation in infant genitals provoked doubt in pediatricians. What did these genitals signify? How would they be used in the future? ISNA formed to oppose the regulation of these bodies through non-consensual interventions on infants. The focus of this activism was not to stop surgeries in any circumstance but to demand that they be done with fully informed consent. As Chase later said: "We don't say: Celebrate that your kid has severe hypospadias or CAH. . . . We say: No unnecessary surgery, no cosmetic surgery without consent" (quoted in Bloom 2003: 124). In effect, this activist critique was a challenge to the medical timeline (do surgery on the child early to help the future adult) and the suggestion of an alternative (wait until the child is old enough to be [End Page 510] part of decisions that affect that future adult). As I have explained, the medical timeline is guided by norms of function and aesthetics. This alternative temporality is structured by norms of consent, bodily integrity, and individual rights (see also Grabham 2012). The medical temporality invokes a future of normal genitals and heterosexual sex; the activist temporality invokes a future of more varied genitals (or perhaps a more expansive view of what constitutes normal) and potential pleasures beyond the heteronormative.
Activist critiques of surgery have argued that surgery fails on its own terms, not restoring a normative timeline but disrupting one. Morland draws on Elizabeth Freeman's (2010: 301) notion of "temporal drag" to think about infant genital surgeries. Freeman expands upon work in queer theory on drag as gender performance to think about drag temporally, as a slowing down, but also as a coexistence of different temporal frames. As Morland (2009c: 301; quoting Freeman 2000: 729) explains: "Surgery is an example of what Freeman has named 'temporal drag'—the registration of 'the co-presence of several historically-specific events' on bodily surfaces." Surgery on infants certainly drags on through life. Tiger Devore (1999: 80) has spoken about the repeated surgeries he was subjected to as a consequence of being diagnosed with hypospadias, roughly one surgery a year by the age of ten and sixteen in total, and how this dragged from the first intervention through the rest of his life:
My childhood was filled with pain, surgery, skin grafts, and isolation. I remember when school vacation came, the other kids went somewhere fun. I went to the hospital during vacation, so I wouldn't miss too much school. When vacation was over, I would return to school, often not yet healed from the latest surgery. Sometimes I went back to school with tubes coming out of me, and stitches and scars, and I couldn't walk well.
Adult testimonies such as Devore's paint a damning picture of the success and risks of hypospadias surgeries.3
Statistics for complication rates are hard to find. Reviewing the literature, Adrienne Carmack, Lauren Notini, and Brian D. Earp and colleagues (2016) found statistics for complications that range from 5 percent to more than 50 percent. Meredith Campbell stated in 1951 (294): "There is probably no plastic procedure in which the results of infection and breaking down of suture lines are more disheartening." Some contemporary commentary indicates little progress in this area. Guido Barbagli and colleagues (2016: e694) stated: "No other congenital anomaly of the human body requires so high number of operations to be repaired." This is [End Page 511] a marked contrast to confident statements published by some surgeons. Alan Park (2017) claims: "This type of operation has a good success rate, with over nine in ten boys who undergo this operation finding that it corrects the issue completely." This is clearly a contradiction, perhaps explainable in part because of the lack of standardization for hypospadias surgeries. Pediatric urologists Ramnath Subramaniam, Anne Francoise Spinoit, and Piet Hoebeke (2011: 206) write that "in trying to describe the reconstructive techniques for hypospadias repair one could state that there are as many techniques and their modifications as there are surgeons who perform hypospadias repair." "Follow-up" is also often taken to mean one to two years, when complications can arise later, including during puberty. This makes getting any reliable data for success and complication rates impossible, a problem compounded by the organization of medicine into subspecialities and the disconnect in care at different ages. All these factors can reinforce the view that surgery is better now than in the past. This potentially allows pediatric surgeons to think their personal technique is effective, while surgeries happening previously or elsewhere might not be. This provides at least part of the answer as to why surgeries continue despite decades of activist challenge.
Queer Theory and the Future
With heteronormativity structuring the medical imagination of what the penis should look like and be able to do in the future, it would seem to follow that queer theories of temporality might be uniquely suited to challenge this practice. One of the most influential texts on queer temporalities, and one that I judge to be applicable to intersex and variations of sex characteristics, is Lee Edelman's No Future (2004). The potent figure of the child is key to Edelman's argument but can be employed for both progressive and conservative arguments. He gives examples of both pro-choice and anti-abortion rhetoric in North America, framing the opposing arguments as a "fight for our children . . . and thus as a fight for the future" (3). Similarly, Patrick McCreery (2008) has drawn attention to the fact that both sides of the debate about gay marriage in North America similarly employ the rhetoric of child protection to support their arguments. As Alison Kafer (2013: 28–29) argues: "For those in both fights, then, the struggle becomes no longer about rights or justice or desire or autonomy but about the future of "our" children. Both of these examples show the slipperiness of arguments based on the Child and reproductive futurity; one can mobilize the same rhetoric toward mutually opposing goals."
The rhetoric of the rights of the child does not necessarily lead to the stopping [End Page 512] of nonconsensual surgeries. Indeed, as I outlined earlier, surgeons in 1968 believed it was every boy's right to pee standing up with his schoolmates. Morland (2007) urges caution around the promise of human rights discourses, highlighting that the history of humanism does not necessarily provide us with an ethical approach to variations of sex characteristics.
Edelman's (2004: 4) formulation of queer refuses the "narrative movement toward a viable political future" and the "fantasy of meaning's eventual realization." Instead, he argues: "What is queerest about us, queerest within us, and queerest despite us is this willingness to insist intransitively—to insist that the future stop here" (4). We might interpret activist resistance to the DSD classification system as just this kind of insistence. After all, DSD was supposed to be the future, framing the language of intersex as outdated and the genetic grounding of DSD as promising clearer definitions and better treatment at some point in the future (Griffiths 2018b). Resisting DSD might well be a resistance to the promise of the future's sorting it all out. There is, however, a tension in insisting on "no future." For hypospadias, a future with such a bodily difference is always already considered necessarily negative and almost unthinkable, and the removal or normalization of such difference is considered desirable.
Edelman tries to maintain a distinction between the Child (with a capital C) and actual children. However, critiques of Edelman stress that the future is not the same for all children. As José Esteban Muñoz (2009: 95) argues: "The future is only the stuff of some kids. Racialized kids, queer kids, are not the sovereign princes of futurity." Kafer's work in Feminist, Queer, Crip (2013: 2–3) draws out this logic clearly for issues of disability and the future, arguing that disabled kids, too, are denied a future: "In this framework, a future with disability is a future no one wants, and the figure of the disabled person, especially the disabled fetus or child, becomes the symbol of this undesired future." I would add that kids with variations of sex characteristics (and indeed any bodily difference from restrictive medical norms) have a similar relationship to futurity, as difference must be surgically removed, "normality" "restored" to get bodies back on the road to normativity; as Grabham (2012: 22) states: "Nostalgic genitals cause bodies to be stitched into normative time-lines." This is relevant to all bodily difference, but individuals with variations of sex characteristics have specific lived experience that often includes the medicalization of their bodies, surgical interventions, and ongoing consequences of these interventions.4
If what queer theory can do for bodily difference is to turn away from fantasies of the future and insist on no future, then where does that leave the dedicated activists who continue to fight for better futures for individuals born with [End Page 513] bodies that do not fit cultural ideals of normality? Activists around the world have worked tirelessly for decades to have all nonconsensual cosmetic surgical interventions on infants considered human rights abuses (Carpenter 2016, 2018, 2020; Bauer, Truffer, and Crocetti 2019; Crocetti et al. 2020). UK-based activists such as Valentino Vecchietti (2018) continue to fight for change to medical practices and protocols, practices that are ongoing despite international bodies such as the United Nations describing them as "torture." The fact that these practices continue despite decades of activist history is what makes the demand for different futures so urgent for activists. As US-based activist and artist Pidgeon Pagonis (2017) put it: "I can't believe we're still fighting this battle." Legal scholars Fae Garland and Mitch Travis (2020b) also emphasize these activist temporalities and identify similar temporal frameworks in legal and legislative responses to intersex.
While hypospadias "repair" is seemingly future-oriented, in practice any futurity collapses in the unique moment of surgical intervention. Urologists do not agree on how to classify hypospadias, which techniques to use, or when follow-up should happen. In one roundtable of pediatric urologists in 2011, the only thing the urologists agreed on was that classification, judgment of severity, choice of technique, and surgical approach could actually only be decided intraoperatively (Snodgrass et al. 2011). That is, surgery can only be thought out once surgery is happening. No future indeed: all temporality collapsed into a single surgeon in a single unique moment. Surgery is seemingly about the future, but in practice it is entirely about unique and singular moments. These are what I have come to think of as "futureless moments," where temporality collapses and in which surgery becomes inevitable. This inevitability structures the clinical and surgical experience, from the medical images discussed earlier to the framing of conversations with family members who are asked to consent. As Snodgrass said during the roundtable: "The only preoperative decision is whether the family prefers circumcision or prepucioplasty [foreskin construction]" (Snodgrass et al. 2011: 2). This is the logic of hypospadias "repair." Surgery is endlessly inevitable, with decision making for parents reduced to a choice (or even a "preference") between circumcising or surgical "restoration" of the foreskin.
Contrary to Edelman, Muñoz thinks of queerness as actually all about the future. Muñoz (2009: 91) is troubled by the call of "no future" in relation to those children who might not be the sovereign princes of the future. For these children, the idea of a future is not a foreclosing of possibility but rather an "opening or horizon." For Muñoz (1), "The future is queerness's domain. Queerness is a structuring and educated mode of desiring that allows us to see and feel beyond the quagmire of the present. The here and now is a prison house. We must strive, in the face [End Page 514] of the here and now's totalizing rendering of reality, to think and feel a then and there." Muñoz also refers to this totalizing quagmire as the "devastating logic of the here and now" (12). I see this resonating with the logic of intraoperative decision making. This is a futureless moment: a unique intraoperative moment, performed by the surgeon with their own preferred technique, with no decisions or agency outside this moment—a moment that never moves beyond the now to a possible future that might hold responsibility and accountability.
Conclusion: "Waiting Is Not Nothing"
For decades, intersex scholarship and activism have challenged the ongoing surgical intervention on genitals deemed "abnormal." Scholars such as Morland and Holmes have argued that intersex surgeries do not normalize bodies but are sustained by a discursive reliance on a promised future of heterosexual, binary-gendered normality. Within this narrative, hypospadiac penises are illusory and easily disregarded in favor of the nostalgic-promissory penis that the surgeon aims to bring into being at some point in the future. Queering the futureless moment of hypospadias "repair" draws attention to the fact that the choice of surgery or of not doing surgery—often presented as "doing something" or "doing nothing"—can be interpreted as shutting down possibilities through surgery or waiting and keeping potential and possibility open. Roen and Hegarty (2018) argue that medicalizing hypospadias leads to a focus on "doing something": that is, intervening surgically. As Roen argued in 2008, the seeming dichotomy between "doing something" (intervening surgically) and "doing nothing" (waiting) structures the narrative used by medical professionals and offered to parents. In the intraoperative logic of the here and now, surgery gains an inevitability, and postponing surgery is "doing nothing." However, as Roen and Hegarty argue, "waiting is not nothing."
Waiting introduces a "time of anticipation." Here, queering the moment of hypospadias "repair" resonates with work on trans temporalities. Ruth Pearce (2018: 131) develops a similar argument to Muñoz in relation to trans experiences of anticipation and waiting: that the limbo of the extended present is not necessarily playful or resistant for those denied agency in the first place. She draws attention to the fact that the "limbo" of the present in a time of anticipation can be unpleasant, restrictive, and damaging to health. However, the time of anticipation is also a time of potential. Pearce sees a possibility of imagining openings and horizons of better individual, community, and political futures. She analyses instances of trans individuals creating and maintaining agency within the time of anticipation, through community-building and information sharing. She refers [End Page 515] to these instances as "strategic futurities."5 The extended present, the futureless now, can be a restrictive, negative time if individuals are denied agency. However, within the time of anticipation, individuals and communities can find ways of creating and maintaining agency and imagining potential possible futures.
Strategic futurities might be necessary to escape the prison house of the present and to forge possibilities other than the inevitability of surgery. There is queer potential in these strategic futurities, guided as they are by bodily integrity and consent rather than function and aesthetics. Holmes (1998: 226) described it in terms of a promise: "'Queer' makes a promise, which I believe can be fulfilled, and that is for all of us 'different folk' to be able to achieve freedom from oppression—which is distinct from the freedom to oppress." The medical profession is promising normality, but this promise is not for the medical profession to make (Holmes 1997/98: 9). A queer promise is a strategic futurity, focused both on lost pasts and on the potential that extending the present has for the future:
I would have liked to be able to choose for myself. I would have liked to have grown up in the body I was born with, to perhaps run rampant with a little physical gender terrorism instead of being restricted to this realm of paper and theory. In theory I can be many things. In theory I could have been many things. But physically, someone else made the decision of what and who I would always be before I even knew who and what I was.
(Holmes 1994b: 13)
In temporal narratives structured by norms of function and aesthetics, individual pleasure and satisfaction are not considered important or, often, are left out of discussions altogether. Within strategic postmedical futurities, however, there is queer potential for pleasure.
Waiting is not nothing. Indeed, it may bring its own difficulties. Earlier I cited Chase's statement: "We don't say: Celebrate that your kid has severe hypospadias or CAH. . . . We say: No unnecessary surgery, no cosmetic surgery without consent."6 The time of anticipation may indeed be a difficult time, and to choose not to do surgery may bring about its own series of further decisions, unexpected consequences, and embodied experiences. And it is important that waiting and anticipation not become simply waiting for, or anticipating, inevitable surgeries in the future. Instead, we might think about Hilary Malatino's (2013: 243) call to transform "the waiting room, making home and building community in spaces of liminality and transience." Agency is central to this transformation for Malatino, as this is a "transformative process that is never finished, one that we—not the [End Page 516] medical establishment, not the state—choose to undergo" (95). And in this transformation, "the waiting room evaporates, for there is nothing left to wait for. There is only the becoming, happening moment by moment, in perpetuity, ever in collaboration and co-production with other agents of becoming" (95).
The futureless moment of hypospadias "repair" is open to queer critique. Further, this "opening up" suggests strategic futurities for intersex and bodily difference more broadly. This queer futurity draws on Muñoz's conceptualization of queerness as a horizon, a future, and the future as queer. Queer theory can offer a way to challenge the moment of hypospadias repair, precisely because the surgical moment is one without a horizon. The devastating logic of "we must do something here and now" can be critiqued by queer theories that value an opening up to a horizon—elsewhere—and resisted with calls to think about a "there and then." Queering the moment of hypospadias "repair" leads us to ask: what horizons are left open, what becomings made possible, with the choice to postpone surgery? To defer it, perhaps endlessly? [End Page 517]
David Andrew Griffiths is currently a lecturer in the Department of Sociology at the University of Surrey. He gained his BA in English literature as well as his MA and PhD in critical and cultural theory from Cardiff University. His research interests include gender and sexuality studies, feminist science studies, and cultural histories of medicine and health. He is currently working on a recent and contemporary history of intersex in the UK.
Notes
I am grateful to Peter Hegarty for detailed feedback at every stage of this article, and to Katherine Hubbard on the final draft. I am indebted to the many intersex activists and scholars with whom I have had productive conversations at a number of conferences and meetings in the last few years. Thanks also go to my friends and colleagues in the Sex, Gender, and Sexualities Research Group at the University of Surrey and to the editor and anonymous peer reviewers at GLQ. Research for this article was supported by Wellcome Trust Grant 106614/Z/14/Z.
1. More recent intersex scholarship has engaged directly with queer theory, including Malatino 2019; Rubin 2017; and Garland and Travis 2020a.
2. It is worth noting that not all individuals with variations of sex characteristics identify with the term intersex or queer or with LGBTQ+ politics. See Lundberg, Hegarty, and Roen 2018.
3. For collections of testimonies from intersex people, see Dreger 1999 and the more recent Davis and Feder 2015.
4. It is informative that medical publications have referred to individuals who have ongoing complications after or as a result of surgery as "hypospadias cripples." This language situates hypospadias as a disability but, interestingly, seems to admit a social model of disability: it is not the bodily difference itself that is "crippling" but the lived experience of medicalization and surgical interventions.
5. While trans and intersex are distinct, they also overlap, and they share an entangled history. See Griffiths 2018a and Hubbard and Griffiths 2019.
6. My argument in this article is of relevance not just to hypospadias but to bodily difference in general. Another area that is of relevance but that is not included here for the sake of space is that of male circumcision. There are clear connections around medicalization, infant surgeries, and issues of consent. For an approach to male circumcision that considers bodily autonomy, ethics, and the rights of the child alongside the rights of the future adult, see, for example, Earp and Darby 2017.
