Abstract
Surgeries inevitably raise questions of bodily integrity: how the post-surgical body reframes (or does not reframe) its experiences of functionality to incorporate new features. Nevertheless, when we try to define or delimit the concept of bodily integrity, it becomes increasingly important to think about how the physical and social unease caused by some forms of surgeries sits alongside the more transformative potential of surgical bodily modification. This article focuses on aesthetic genital surgeries on infants with disorders of sex development (DSD, previously termed ‘intersex’ conditions). Using the work of Pierre Bourdieu and Elizabeth Freeman on time, bodies and ‘chrononormativity’, this article excavates not only the temporalities that produce what I would term ‘chrono-abnormalities’ of sex development, but also the temporalized medical responses, including surgeries, which retrieve ‘abnormal’ bodies into more normative time-lines. My conclusion is that when DSD-affected individuals experience aesthetic genital surgeries as painful and full of social unease this is not necessarily because the pre-surgical body was the ‘natural’, ‘whole’ or ‘intact’ body prior to surgery. Instead, it is because these surgeries interrupt what Bourdieu would term a sense of corporeal ‘immersion into the forthcoming’; an immersion which, in his theory of time as social action, is intimately linked with social power and possibilities.
Elizabeth Freeman recently wrote that ‘temporality is a mode of implantation through which institutional forces come to seem like somatic facts’ (2007: 160). Freeman’s work provides a useful intervention into what is, by now, a significant body of scholarship on the social and cultural dynamics of time (see, for example, Adam, 1998, 2002, 2003; Funke and Davies, 2011; May and Thrift, 2001; Szerszynski, 2001). In Freeman’s opinion, temporal mechanisms are central to the operation of biopolitics in the contemporary era. As such, it is necessary to trace which temporalities become socially and politically significant to the management of bodies as well as populations (Freeman, 2005). Freeman’s recent book Time Binds: Queer Temporalities, Queer Histories (2010) provides further elaboration of her concept of ‘chrononormativity’, which describes the re-embedding of dominant temporal frames such as the life course, the time of the home and hearth, and/or the time of reproduction through social structures and power relations. Further than that, however, it also provides a set of critical tools to begin a political analysis of time’s normative processes: Manipulations of time convert historically specific regimes of asymmetrical power into seemingly ordinary bodily tempos and routines, which in turn organize the value and meaning of time. (Freeman, 2010: 3)
I analyse these questions by focusing on the embodied effects of aesthetic genital surgeries on infants with ‘disorders of sex development’ (‘DSD’). Such disorders were previously termed ‘intersex’ conditions, but in a move toward productive engagement with medical practitioners, activists have begun using the term DSD, and this article reflects that shift. The core assertion of this piece is that while all surgeries are transformative in one way or another, an expanded idea of bodily temporalities is needed to account for the potentially more variable social and corporeal effects of surgeries, and of infant aesthetic genital surgeries in particular. Such an analysis will hopefully assist ongoing interdisciplinary research on the ways in which legal regulation constructs and uses embodied time-lines, and contribute to debates in the sociology of embodiment on the productive interconnections between time, corporeality, bodily integrity and surgeries.
Surgeries inevitably raise questions of bodily integrity: how the post-surgical body reframes (or does not reframe) its experiences of functionality to incorporate new features. As a recent special issue of this journal indicates, social theories of bodily integrity provide a rich array of perspectives on the lived experience of corporeal change, medicalized or otherwise. A key insight of these perspectives is that a propertied or sovereigntist understanding of embodiment as the subject’s ownership and determination of the soma is often usefully surpassed, or augmented, by other theoretical imaginings of embodied selfhood, such as ideas of bio-social entanglements between cultural, social and technical processes (Blackman, 2010). These ideas challenge not only individualized understandings of embodied becomings and corporeal subjectivity, they also increasingly blur our understandings of the conceptual and material boundaries between bodies themselves. As Aryn Martin (2010) shows, for example, scientific and social theories about microchimerism and the survival of fetal cells in women’s bodies after pregnancy are reconceptualizing what the concept of bodily integrity means. Bodily integrity might just as well therefore mean functional cohesion or cellular coexistence as much as it evokes concepts of autonomous personhood.
Yet moving towards more socialized understandings of bodily integrity still requires theorizing embodied selfhood. In a recent article, Jenny Slatman and Guy Widdershoven (2010) investigate how hand transplant surgery impacts on bodily integrity. They analyse the experience of Clint Hallam, whose ‘new’ hand felt entirely strange to him and who eventually required a re-amputation, alongside the experience of Denis Chatelier, who incorporated his two new transplanted hands into a concept of ‘self’. Through contrasting stories of ‘successful’ and ‘unsuccessful’ transplants within a phenomenological-narrative approach to bodily integrity, Slatman and Widdershoven reach the conclusion that ‘normalizing’ interventions are not always justified because they might violate, instead of complete, a person’s sense of bodily integrity (2010: 87). In other words, surgeries that are pursued with the aim of re-establishing wholeness can, paradoxically, disturb a person’s already-existing phenomenological construction of integrity.
In the light of Vivian Sobchak’s innovative autobiographical/phenomenological analysis of her own experiences of prosthetic leg surgery, it should not necessarily be surprising, as a matter of bodily integrity, that surgeries might have such varying results and ethical implications. As Sobchak puts it: I primarily sense my leg as an active, quasi-absent ‘part’ of my whole body. That is, unless there is an occasional prosthetic problem which provokes a sense of irritation at the alienated body-object that I ‘have’ rather than transparently and intimately ‘am’…. I do not focus on or feel my leg as ‘some thing’. (2010: 62) the issue to hand is not simply that of bodily modification where a certain obeisance to corporeal integrity remains, but that of the insistent potential of radically different modes of embodiment, regardless of whether such transformation is intentional or otherwise. (2010: 11)
Ideas of proliferation and linear or non-linear development are therefore fairly common to social analyses of surgical alterations. These ideas bring with them the broad proposition that surgeries and new forms of intervention might, in some incarnations, be generative; that these modifications might shape or govern new forms of belonging and becoming. Nevertheless, many surgeries, such as the hand transplant surgeries analysed by Slatman and Widdershoven, fail to hold out such possibilities for extension and development; they cause pain or they interrupt a sense of ease and immersion in social life.
It is this question of how to account for the physical and social unease alongside the potential of surgical bodily modification that the present article addresses. Here, the focus is on aesthetic genital surgeries on infants with DSD. Surgeries to normalize ‘atypical’ genitalia on infants diagnosed with DSD have come under a huge amount of scrutiny in recent years, as activists and scholars have challenged the practice of operating on otherwise ‘healthy’ tissue to produce normative aesthetic results while often compromising sensation and causing ongoing problems (for example Holmes, 2002; Kessler, 1998). Intersex activism has forged new relationships with clinical practitioners, with one organization (the Accord Alliance) adopting the term ‘disorders of sex development’ to describe what were previously termed ‘intersex’ conditions (Dreger and Herndon, 2009). An increasing level of academic work has also focused on medico-cultural understandings of DSD (Morland, 2005a), the racialized and sexualized representation of genitals (Fox and Thomson, 2009; Njambi, 2009), familial decision-making dynamics (Murray, 2009) and the relationship of intersex activism to broader sexual citizenship claims (Grabham, 2007) and to queer theory (Morland, 2009).
Scholars and activists working on medical and social responses to DSD show that concepts of ‘harm’, ‘consent’ and ‘injustice’ are ill-suited to the complex ethical problems posed by DSD as a lived, and medically mediated, experience (see in particular, Morland, 2005b, 2008). As Iain Morland puts it: ‘intersex management becomes discernible as an ethical problem precisely when the distance collapses between correcting intersex and living with it – when one finds oneself living with the medical correction of intersex variations’ (2008: 429). It is this collapse between the correction and the lived experience, between the aesthetic genital surgeries and their ongoing effects, that makes theories of bodily integrity potentially so useful for understanding the social context of DSD surgeries. However, many of the surgical effects in this context also impact on ideas of lived temporality: expanded or restricted social horizons, different interpretations of pain (‘restorative’ as opposed to ‘damaging’), for example. My argument, therefore, is that understanding the social and ethical effects of surgeries requires addressing the relationship between corporeality and temporality. In other words, surgeries, and their effects on bodily integrity, can and should be theorized as temporal phenomena, or at least as processes heavily influenced by ideas of time.
Using Pierre Bourdieu’s theory of time as social action, I investigate how the socialized body unfolds through surgical technologies, and how particular ideas of temporality support and sustain the surgical extension (or manipulation) of DSD-affected bodies into new forms and shapes. Bourdieu’s work is particularly useful in this context because it shows how embodied social agents create time through their engagement with the social field and through their empowered relationship to the ‘forthcoming’ (Bourdieu, 1990, 2000). As such, Bourdieu provides an embedded, intensely corporeal sociological account of the development of what Freeman would term ‘chrononormativity’. In this article, I use Bourdieu’s work to contextualize theories of bodily integrity and connect them with work on the sociology of time, in order to provide fresh perspectives on the effects and implications of aesthetic surgeries on infants with DSD. Infant aesthetic genital surgeries approximate what Morland (2005a) has termed ‘nostalgic genitalia’ – normative ideas about ideal male and female genitals. Yet the temporal presuppositions, timely mishaps and developmental teleologies that support these surgeries are less often subjected to scrutiny. Bourdieu’s work provides us with some of the means to begin this analysis.
In the first section of the article, I introduce two medical temporalities which exert effects on DSD-affected bodies: the cascading time of sex development, and the time of ‘repair’ and ‘retrieval’. The second section picks up on the social consequences of these productive temporal narratives, using Bourdieu’s work on time to re-centre the relationship between the lived experience of aesthetic genital surgery on the one hand, and agents’ engagement with the social world on the other. In sections three and four I introduce the concept of social prosthesis as a means of linking Bourdieu’s concern with social time to more recent theoretical work on the generative possibilities of corporeal modifications, and therefore avoid reducing surgeries to ‘harm’. I conclude by arguing that putting surgeries within Bourdieu’s theory of time allows an analysis of how infant aesthetic genital surgeries interrupt particular corporeal forthcomings, with varying effects on patients’ lived experience of social ease. This temporalized understanding of surgeries brings with it first, new perspectives on the ethics of altering infant genitalia for aesthetic reasons and, second, a wider range of perspectives on the social experience of body modifications.
Medical Temporalities: Cascading Time and the Time of Repair
Medical discourse and practice operates, in general, with a number of temporal assumptions. These assumptions go to the heart of how to diagnose abnormalities on the one hand, and what to do about those abnormalities on the other. As such, diagnostic and treatment-related temporal assumptions can be characterized as forms of medicalized chrononormativity, to adopt Freeman’s terminology. The aim of this first section is to trace the embodied effects of two clusters of temporal norms that influence medical attitudes to DSD-affected subjects in particular. First are those norms which constitute the cascading time of generation, development and ‘abnormalities’. These ideas produce what Freeman would call ‘seemingly ordinary bodily tempos’ (2010: 3), from which DSD-affected bodies are thought to diverge. Second are the norms which explain and justify particular medical strategies, such as the performing of aesthetic genital surgeries on infants. I have characterized these norms, collectively, as the time of retrieval, or the time of medicalized becomings. In other words, the distinction in this section is between temporalities which construct sexed chrononormativity, or chrono-abnormalities, in the body, and those temporalities which support surgical interventions into embodied chrono-abnormalities.
Cascading Time: The Construction of Chrono-abnormalities
In the first ‘type’ of time, ‘cascading’ generation or development, sex is produced through a sequencing effect, where hormonal, gonadal and morphological stages follow on from each other. The (heavily abridged) medical narrative is that chromosomal sex determines the hormones which, in utero, lead to gonadal development (the growth of ovaries and testes), duct differentiation (the growth of spermatic ducts or fallopian tubes and uterus) and genital development (for females, clitoris, labia and vagina and for males, penis and scrotum). Mobilizations of this type of time can invoke normative (‘passive’ ovaries, for example, and ‘masculine’ testosterone: see further Fausto-Sterling, 2000) or anti-normative concepts of gender and sex roles, and they often use a mixture. Vernon Rosario (2009), for example, critiques representations of sex development that pose the SRY gene as the dominant gene that switches otherwise ovarian tissue to testicular tissue. He argues that these journalistic and medical stories are anthropomorphic, employing, as they do, tropes of ‘ovarian fatalism’ and ‘Y-chromosomal pride’, the logic of which can be traced back to Aristotle’s positioning of the male as active and the female as matter (2009: 269, 273).
In the more normative and binaristic stories, cascading time in the development of children with DSD happens outlandishly or excessively, into the ‘wrong’ direction, producing sex-related outcomes that do not match a ‘typical’ morphology. This is the time of aberrance: bodies that could have flourished and unfolded in the ‘appropriate’ manner are perceived instead to have been skewed or have gone awry, developed into ‘unrecognizable’, ‘strange’ or ‘disordered’ patterns. It is also a problem of disturbed sequencing: the testosterone has not had the desired effect; the gonads do not produce the required hormones; and therefore the imagined developmental time-lines cannot happen. And it is a problem of temporal splitting, as if time has divided at a certain point and left these bodies developing along a path (the ‘wrong path’) that they did not deserve.
Within narratives that are less attached to normative (specifically hetero-normative) stories of development, temporal splitting is represented in terms of ‘branching’ and ‘pathways’, but it has similar discursive effects. The Toronto Hospital for Sick Children (THSC), for example, has produced an educational tool on sex development for its website which avoids gendered language, as well as the language of medical ‘abnormalities’ in DSD-affected children, presumably reflecting a shift among progressive medical practitioners and carers to a more open-ended and non-judgemental attitude to sexual and bodily diversity (THSC, 2009). Visitors to the site are directed initially to a tab entitled ‘Sex Development’ featuring an animated picture of a growing plant, with the wording ‘All babies grow toward the light’ at one side. As the visitor clicks on the tabs (‘next’ and ‘back’), the wording explains that other babies ‘branch off and take a different path’, growing, as they do, with uro-genital conditions that make them look different from other children and require medical care (THSC, 2009).
Within ‘normal’ cascading stories of sex development, the growing fetus reaches a number of stages, or branches, at which different pathways meet. Then, according to factors influenced by chromosomes, hormones, as well as the body’s ability to respond to hormones, the body unfolds into different shapes or is driven to particular sex outcomes. It is not necessarily the content of the various stages that is important here: rather the chronological, sequential nature of the corporeal time-line is what is at stake. Navigating the THSC website reveals that, despite pedagogical attempts to neutralize the sex/gender language, it is the temporal norms of sequenced growth, along with their sequenced representation through ‘next’ and ‘back’ tabs, which re-introduces binaristic models of ‘active’ male and ‘passive’ female development. 2
Within the information for gonadal development, for example, visitors can learn that if the fetus has a Y chromosome with the SRY gene at the stage of gonadal development, then the gonads produce a protein called testis-determining factor (TDF), which causes otherwise indifferent gonads to develop into testes. If, however, there is ‘no Y chromosome’ then the gonads develop into ovaries. Likewise, within the information about duct differentiation, visitors learn that fetuses of up to six weeks of age contain both Müllerian and Wollfian ducts. In male fetuses at the stage of duct differentiation, the testes (1) make a hormone called Müllerian Inhibiting Substance (MIS) which causes the Müllerian ducts to disappear, and (2) make the hormone testosterone, which causes the Wollfian ducts to grow into spermatic ducts. The story, once again, is simpler for female fetuses: there is no testosterone so the Wollfian ducts disappear.
Both examples reveal Aristotelian logic: the male fetus develops through its sequential stages ‘because of’ certain factors (Y chromosome, testes, testosterone) and the female fetus develops through its stages ‘without’ those very same factors (without the Y chromosome, without testosterone) (see further, Rosario, 2009: 273). As Rosario puts it, this logic takes female sexual development to be the result of a ‘genetic deficit’, which positions the ovary to be a ‘default organ requiring no particular genetic machinery worthy of investigation’ (2009: 273). (By contrast, recent advances in genetics research have fundamentally undermined the idea that the Y chromosome, on its own, determines male sex (2009: 274).) 3 The normative sex development teleology (the causation model) begins with the Y chromosome and follows it through to testes, testosterone, the morphology of the penis and the ‘natural’, male, outcome. It does so because of, not merely alongside, its chronological character: the number of weeks after conception, the stages, the deciding moments, which themselves trigger questions of presence and lack, this path or that. Even in relatively progressive representations, ‘typical’ female development (the inaction model) represents an alternative, if analogous, time-line to the teleology of the Y chromosome and its apparently associated effects. Here, the XX fetus does not generate testosterone and therefore does not develop testes. Its Wolffian ducts do not grow – they disappear, and the female genital area does not develop into scrotum and penis.
But Aristotelian logic also operates with temporal assumptions. In these representations of the timely development of normally sexed male and female fetuses, the female fetus is caught in an absence of action, a resignation or lack of initiative, from which its morphology and specifically its genital appearance ensues. In this way, positioning female chromosomal and hormonal development factors within a social analysis of time reveals these female characteristics to be (supposedly) relatively disempowered social actors in temporal narratives of sex development. This is perhaps the reason why clinicians regard so-called ‘virilized’ female genitals – large clitorises for example – with such concern. A large clitoris signifies an excess of time and action within an overarching narrative of, as Rosario puts it, female fatalism and inaction. By contrast, a ‘severe’ case of hypospadias signifies a lack of time where the expectation is of dynamic and timely male development: premature or interrupted development during the phase in utero when the labio-scrotal folds (as the THSC puts it) would otherwise ‘zip up’ to form the penile urethra (THSC, 2009).
If even the ‘normal’ male/female developmental binary is overlaid with the cascading cause and effect temporality of the Y chromosome/testosterone matrix, then the wide array of alternative chromosomal and hormonal combinations that make up the classification ‘disorders of sex development’ are reinforced as untimely at every stage. This is borne out by the THSC’s educational tools for two other intersex ‘conditions’: androgen insensitivity syndrome (AIS) and 5-alpha reductase deficiency (5-ARD). The tool describes AIS and 5-ARD as conditions in which a person with the chromosomal make-up 46 XY (usually classified as male) does not respond to masculinizing androgens produced mainly in the testes (THSC, 2009). People with partial or complete AIS have external genitals that look either completely female (complete AIS) or ‘not exactly like typical female or typically male genitals’ (partial AIS and some cases of 5-ARD) (THSC, 2009).
Under the next section, ‘How Androgens Work’, visitors are informed that androgens (testosterone and dihydrotestosterone) are needed for the development of male genital anatomy. In ‘The Androgen Receptor’ section, visitors are then told (again with tabs ‘next’ and ‘back’) that testosterone usually binds to an androgen receptor in cells, which activates specific genes responsible for male sex development. If the androgen receptor does not work because of a ‘genetic mutation’ then the testosterone cannot have its usual effects and the unbound androgen will turn into estrogen, ‘usually thought of as a “female” hormone’ (THSC, 2009). In fetuses with complete androgen insensitivity syndrome, the Wolffian duct cells degenerate because they cannot respond to testosterone. The testes remain inside the body and the lower part of the vagina forms separately, resulting in a short ‘blind-ending’ vagina that forms because the testosterone is not present to stop it (THSC, 2009).
The cascading temporality of the Y chromosome/testosterone matrix again influences the normative teleology of sex development. But in this case, instead of absence (the lack of testosterone), DSD morphology in the case of complete AIS is explained through tropes of escape (the vagina that develops because testosterone is not present) and insensitivity, or the androgen receptor’s lack of feeling, tactility and response to testosterone. The developing AIS fetus (and its chromosomal and hormonal make-up) is seen to act on time to a certain extent, but the acting is incomplete, interrupted or diverted, as is the case with the developing fetus with hypospadias. As a form of generation or growth, DSD development is therefore positioned as having an ambivalent relation to the future.
Medicalized Becomings: The Treatment of Chrono-abnormalities
If chrononormativity influences narratives of sex development, then it also has a part to play in aesthetic surgical treatments for infants with DSD. The medical response to these apparently ambivalent futures is one of taking back or reclaiming DSD-affected bodies into the time of the (constructed) sex binary, where morphology fits social expectation. Clinicians’ talk of starting DSD patients out ‘on the right path’ (Roen, 2008: 50) references unease with what is seen as a temporal splitting on the part of the developing fetus in utero. Through these narratives, surgery is positioned as retrieval, cutting away unintended growth and refashioning developmental time-lines.
There are some common temporal themes to surgeons’ stories about these surgeries. First is the theme of incrementalism. As Katrina Roen points out, challenges to the conceptual underpinnings of aesthetic genital surgery, when considered at all, are considered ‘one body part at a time’ (2008: 52). Through a form of sequencing, this distances the reasoning applied to one body part from the reasoning applied to another. The second prevalent temporal theme is of ‘follow-up’ surgery or associated ‘repair’ procedures. Genital surgeries on DSD-affected infants and children cause many types of ongoing complications – urinary tract infections, the requirement for repeated catheterizations, the necessity of dilating a constructed vagina, ‘corrective’ clitoral or vaginal procedures that require further ‘correction’, sometimes resulting in numerous operations over a 10- or 20-year period (see Kessler, 1998). By its very nature, surgery on children is extremely likely to require ‘follow-up’ because of physical growth as well as the emergence of new techniques, although, as Roen (2008: 55–6) points out, the type of follow-up is dependent on the type of surgery initially undertaken.
The concept of follow-up, like the concept of repair, implies a therapeutic return or going back, where the initial rationale for surgery is still taken to be valid and justifiable. This is the idea of repair as augmentation: with each return, the procedure gets better and the surgery more accurate and beneficial. Going back is a linear reversal or detour, the object of which is a moment in the past which is temporally distinct from present action. As such, while it operates with a level of disjuncture, going back does not challenge the teleology and imagined end-point of surgically enabled sex development. In fact, locating the problem in the past enables what would otherwise be classed as ‘new’ procedures and provides a justifying context for the associated risks of those procedures.
The final concept, for these purposes, is the concept of the surgical ‘learning curve’, which aligns the surgeon’s own teleology of improvement with the surgical treatment of intersex agents. In her survey of clinical publications on intersex, Roen (2008: 58) points out that surgeons performing hypospadias surgery, for example, accept a fairly long ‘learning curve’, during which surgeons operate on intersex agents with a less than optimal standard of technical competence. Like the concept of ‘repair’, the learning curve is justified by reference to a temporally distinct moment, but whereas ‘repair’ is focused on the past, the justification for the ‘learning curve’ is found in the future (with what are hoped to be improved treatments). In the context of hypospadias, for example, the effect of the learning curve is that a technically unresolved or unfinished procedure (in the surgeon’s own time-line of development) is performed on an intersex agent in order to effect the child’s medicalized sex becoming. While aiming at the future, the learning curve allows relatively unpracticed procedures to take place in the present, which may later become the object of ‘repair’ surgeries. In this way, the temporal fixing points shift between constructed ‘past’, ‘present’ and ‘future’ action and problems, allowing clinicians to justify surgery on the basis of temporal location.
Corporeal Coincidences: Temporalizing Bodily Integrity
The temporalities contained in medical narratives of DSD – the cascading temporality of the Y chromosome/testosterone matrix, with its associated splitting and divergent ‘pathways’, and the medicalized becomings achieved through ‘repair’, ‘follow-up’, and the ‘learning curve’ – therefore have a variety of effects. Overall, Freeman’s concept of chrononormativity allows us to trace the ‘folding in’ functions of these temporalities on DSD infants and children on a larger social scale. Yet, I would argue, viewing these molecular, chromosomal and morphological temporalities through a Bourdieusian framework allows a slightly altered, but extremely useful, scale of analysis, one in which we can trace incremental operations of power at the level of the socialized body itself. This is merely a shift in focus, because Freeman’s own work has been influenced by Bourdieu to a certain degree (see Freeman, 2010). But the reason for performing such a shift is that, in effect, it allows us to bridge Freeman’s concept of social chrononormativity on the one hand, and theories of bodily integrity on the other. In other words, this analysis provides a means of reading time into the socialized production of the ‘integrated’ body.
As readers will be aware, Bourdieu used the concepts of ‘habitus’ and ‘field’ to describe and analyse agency, social action and social systems. When there is a correspondence between habitus and field, between the structures and systems within the field and the agent’s embodied dispositions, then, Bourdieu argued, the agent encounters the world as meaningful and full of possibility. Bourdieu’s idea of temporalization is encapsulated in his idea that social agents create time through social practice, instead of merely existing in time, as the metaphysical account would suggest (Bourdieu, 2000: 206). Time is an integral aspect of social agents’ experiences of power in the world, because a sense of time, or a ‘practical anticipation of the forthcoming’, fundamentally mediates her relationship with the world. The embodied habitus (or agent) produces time through the many ways in which habitus orients itself, temporally, in relation to its own future action in the social field and in relation to what the social field may deliver.
This analysis contains many similarities to discourses of bodily integrity, to the extent that experiences of embodied ease, synchronicity and even ideas of corporeal autonomy, are constructed in productive tension with the social world. What Bourdieu’s theories can offer in relation to these often phenomenological accounts, however, is a specifically temporalized account of bodily transformation, which nevertheless also provides a means of analysing social-corporeal dynamics on a small scale for their varying social effects. Understanding bodily integrity through a Bourdieusian notion of time allows us to do justice to the shift away from autonomy and sovereignty in recent work toward understanding the bio-social interconnections that experiences of embodiment and corporeal change entail. However, it also allows this analysis to take place without prioritizing one bodily state (for example, pre-surgery or pre-corporeal change) over another.
For example, quite predictably, the cascading time of sex development can be seen as a generalized tendency or norm within the field, which creates social constructions of morphological abnormalities, and which justifies the practice of aesthetic genital surgeries on children. These surgeries, which are variously understood as ‘repair’ or ‘retrieval’, could be understood to ‘rupture’ agents’ experience of being immersed in the forthcoming, their temporalized sense of bodily integrity. Indeed, it could be argued that it is an orientation to our present and future corporeal state that allows our bodies to be felt as broadly ‘integrated’ over time. If then, as Bourdieu states, time is only really experienced in the rupture of expectations and chances (2000: 208), because otherwise action in the field is felt as immersion, it follows that experiences of infant genital surgeries could be defined as temporal ruptures, or disjunctures, between bodily anticipation of the forthcoming (this body, as it is now, or a sense of bodily integrity) and what medical practitioners deliver on and through the body (modification, excision, which might, as Slatman and Widdershoven point out, not produce feelings of ease at all but instead, dis-integration (Slatman and Widdershoven, 2010)). The pain, embarrassment and other repeated problems associated with infant aesthetic genital surgeries interrupt patients’ sense of being engaged with and oriented to the social world, and hence also interrupt their ongoing temporalized experiences of corporeal empowerment.
However, if the norms that circulate within the social field suggest that a range of developmental teleologies exist and that aesthetically varying genitals always fit within this range, then there are further alternative possibilities for aesthetic surgeries. (Arguably, progressive scientists and medical practitioners are already attempting to work with such an analysis, despite the problems outlined above.) Aesthetic genital surgeries could either be experienced as a means of opening out the embodied habitus to new sexed futures. Or, if carried out in less empowered circumstances, these surgeries interrupt agents’ sense of immersion into the forthcoming. It is not, therefore, that aesthetic genital surgeries are always problematic in the context of DSD diagnoses. Instead, what causes difficulties is the medicalized over-identification of ideas of retrieval and repair with ideas of becoming. This over-identification leads, through the performing of aesthetic genital surgeries, to an interruption in DSD-affected agents’ sense of becoming or immersion in the social world: their temporal experience of social engagement and empowerment.
Understanding DSD genital surgeries as temporal interruptions operates with the foundational presumption that the trajectories that all bodies pursue, developmentally and culturally, are characterized and lived through social experiences of time, and that these experiences of time may shift in gradual or sudden ways, depending on bodily morphology or cultural interventions. Surgeries on the body can just as well interrupt a sense of immersion in the forthcoming – an empowered sense of social ease – as much as they might smooth the fit between embodied being and social expectations. The concern with this analysis, however, is the alignment of interruption per se with normative concepts of ‘harm’ and ‘damage’. Rupture normally implies breakage; disjuncture normally implies dissonance. Even if it is accepted that genital surgeries cause temporal interruptions, the implication here might be that these are interruptions of otherwise happy and healthy corporeal time-lines. A huge range of recent work, on the other hand, investigates the vissicitudes of agency, consent and subjectivity in relation to different types of surgery, whether aesthetic, prosthetic or otherwise (see Braun, 2009; Davis, 1995, 2002; Smith and Morra, 2006; Sullivan, 2004). If, as already indicated, the body is malleable and plastic, open to proliferating change through surgeries, then the changed post-surgical body cannot always be aligned with damage but can often also be understood in terms of generation (cf. Sullivan, 2009a).
For this reason, it might be useful to characterize all surgeries, as temporal interruptions. Within such a conceptual framework, temporal interruptions can be analysed for their social effects, positive or negative, generative or constraining. However, there are two problems with this analysis. The first is that within Bourdieu’s analysis there is a very clear distinction between being immersed and therefore socially empowered, on the one hand, and experiencing a sense of social disempowerment, on the other. Some surgeries ease a person’s experience of immersion into the social field, and so they cannot, in this analysis, be termed ‘interruptions’ as Bourdieu would have it. The second problem is that characterizing all surgeries as interruptions implies that bodily time-lines are somehow independent of technological engagement unless and until they are ‘operated on’.
One response to these problems might be (1) to retain the idea that some surgeries, when carried out in particular conditions, ‘interrupt’ an agent’s sense of immersion into the forthcoming, but also (2) to de-naturalize the very idea of a corporeal time-line or teleology, thereby undermining the idea that surgeries interfere in ‘natural’ corporeal time-lines.
Surgeries as Social Prosthesis
De-naturalizing an idea of the natural, pre-surgical corporeal time-line requires an analysis of how surgeries interact with particular bodily trajectories. Whilst Bourdieu’s theory of time provides useful frameworks for thinking about the socialized teleologies that shape surgeries, nevertheless his work is more concerned with how social structures (such as class) exert themselves durably on the body than it is with theorizing the corporeal proliferation that surgeries bring about, and the social effects of such proliferation. What is needed, therefore, is a conceptual basis for understanding corporeal generation and relatively rapid transformation within the embodied habitus as it applies to surgeries. The concept of social prosthesis seems to provide one route into such an analysis.
There has been a considerable amount of commentary, recently, on how the concept of prosthesis has been deployed, and, in some arguments, misused, within social theory (see for example Neuman, 2010; Smith and Morra, 2006). Elizabeth Grosz (2005) argues that prostheses, more generally defined, are characteristic of the body’s tendencies to open up its sphere of potential actions. Far from being a signal of corporeal lack, prostheses indicate the ongoing transformation of the human form in many different respects, including, but not restricted to, the usually cited fitting of prosthetic limbs: Are prostheses an attempt to substitute for and augment the body’s organic inabilities? … Or conversely, should prostheses be understood more in terms of aesthetic reorganization and proliferation, the consequence of an inventiveness that functions beyond and perhaps in defiance of pragmatic need? (Grosz, 2005: 147)
Social prosthesis, in Grosz’s terms, therefore works temporally; it is a generative orientation to the forthcoming but it is also, as Bourdieu would remind us, intimately linked with socialized possibilities: social time. Prosthesis is always politically and socially charged; it is shaped by social conditions and its effects are felt differently depending on agents’ social status. Time as social practice exists within the interplay of habitus and field, within the practice of historically situated and embodied dispositions. For its part, social prosthesis describes the flourishing (however it is normatively defined) that occurs when the sense of the forthcoming fits social structures and effects material (for example, corporeal) change. When there is a coincidence between field and habitus, the extension inherent in social prosthesis (such as surgery) is felt as immersion. When there is not a coincidence between field and habitus, or an empowered relationship between agency and the social world, then prosthesis (such as surgery) can be felt as an interruption into one’s sense of the forthcoming, experienced as bodily integrity.
However, drawing again on Bourdieu, the effects of prosthetic change – food, architecture, surgeries – are also already part of the embodied habitus or agent at any point in time. This is because they exist within a range of technological possibilities that are incorporated into the body through constant engagement between the embodied habitus and the social field. The embodied habitus contains within it the possibility of prosthesis because it incorporates aspects of the field – that is, the range of technological (including surgical) and intellectual extensions present within the social world. If social practice creates time, then the corporeal temporalities that are produced by the extension and transformation of the body through prosthesis (into the built environment, into food sources, into new corporeal forms through surgeries) should be understood in radically contextualized ways.
Furthermore, what links most types of social prosthesis is that they avoid cause-and-effect type temporalities in relation to the body. It is no longer possible to talk about the ‘before’ of the body and the ‘after’ of surgery, for example. If surgeries (rapid corporeal transformation) are understood as social prostheses, in Grosz’s terms, then they are already part of the social field in which the agent operates. Given the necessary alignment between conditions existing in the field (social attitudes to gender, for example) and the body’s dispositions (movements, morphology), surgeries prosthetically emerge in or on the body, with differing temporal, corporeal and political effects, either interrupting or easing the agent’s experience of the social world. Prosthetic interruptions do not damage what is already there (the ‘before’ of the body) but instead produce experiences of social and corporeal un-ease through the socialized practice of time on the body.
Strange Times
Prosthetic interruptions, for example, can describe the types of genital surgery performed on DSD-affected infants that have long-lasting effects on sensation and form: clitoris reductions, creation of a vagina, treatments for hypospadias. When a DSD-affected child undergoes genital surgery, their experience of the field brings with it restricted or obliterated physical sensation and, in many cases, social unease (Chase, 1998; Holmes, 2000; Kessler, 1998). Activist, and much scholarly work emphasizes that many genital surgeries have effects that close down important other possibilities or orientations to present and future action (Chase, 1998; Holmes, 2002; Kessler, 1998; Morland, 2005a, 2009).
Iain Morland has already covered the far-reaching teleological effects of these surgeries. ‘Technology such as the scalpel’, he writes, ‘extends the temporal reach of the surgeon’s touch’ (2009: 300). The surgical touch exists outside of the time of cutting, shaping, re-forming – outside of the simultaneity of surgeon and patient – and persists into the body’s futures. That is to say, it extends forward into what is perceived to be a linear forthcoming: the accomplishment of medical intervention is its ability to reiterate continuously its sexing effect, over the course of a patient’s life, in the absence of the surgeon…. [T]he teleology of surgery does not conclude at the time when the patient leaves the operating theatre. Rather, it plots the patient’s whole life as a life of unambiguous sexual certainty, from moment to moment, toilet to toilet, lover to lover, and from locker room to locker room … (Morland, 2005a: 341)
The connections between time and strangeness or dissonance are important here. Bourdieu states that ‘(t)ime … is really only experienced when the quasi-automatic coincidence between expectations and chances, illusion and lusiones, expectations and the world which is there to fulfil them, is broken’ (2000: 208). As we have seen above, genital surgery is one example of a wide range of aesthetic surgeries that take, as their object, the culturally constructed body. That is to say, technologies used on DSD-affected people (including surgeries) are always part of the body’s potential forthcoming at any point. The continued appearance and reappearance of the material effects of nostalgic genitalia on the body is therefore felt as an interruption not because the pre-surgical body without surgery was the ‘natural’ body, but because nostalgic genitalia interrupt the sense of corporeal immersion into the forthcoming. What makes aesthetic genital surgeries problematic in the context of DSD is not the fact that they are surgeries as such, because surgeries form part of the field of transformation in which the habitus opens up, prosthetically and corporeally, to different futures (following Grosz), but instead that this prosthetic opening up, this coming together of field and habitus, breaches the otherwise comfortable, easy and confident orientation to, and immersion in, the social world.
Concluding Remarks
Models of sex development as cascading genetic and chromosomal generation position DSD morphology as an aberrant future or an unintended forthcoming, amenable to retrieval or repair through genital surgeries. In this way, corporeal chronologies have symbolic and material effects on embodied agents and their experiences of bodily integrity. Furthermore, the temporal disjunctures experienced by the recipients of aesthetic genital surgeries are themselves produced and supported by medicalized discourses of becoming. These discourses include concerns about the future of the surgical patient: that she or he will need a noticeably female or male genital structure for healthy psycho-social development; that without surgery the DSD-affected child will be bullied at school or traumatized at the sight of their own genitalia (Roen, 2008: 50). Such discourses also include concerns about puberty, and about setting the child off on ‘the right path’ in life (2008: 50). However, medicalized discourses of becoming also refer to the medical establishment’s chrononormative concepts of sexed becoming, which reach, as we have seen, from understandings of fetal development through theories of childhood to decisions about how to achieve ‘normal’ adulthood. If the temporal norms that structure medico-cultural understandings of sex development in utero are characterized by the cascading effects of the Y chromosome/testosterone teleology, then post-birth, the story becomes the practitioner’s, and here the surgeon’s, temporalized story of professionalism and medical accomplishment.
Morland’s concept of ‘nostalgic genitalia’ is so forceful because it reminds us that the ideals driving genital surgeries on DSD-affected infants are not merely a mirage; they constitute a form of socialized corporeal proliferation – part of the social’s constant engagement with the soma. Nostalgic genitalia cause bodies to be stitched into normative time-lines. Acting together within the social field and also within the embodied habitus, these temporalities achieve prosthetic ruptures on the bodies of intersex agents and force our understandings of bodily integrity into new directions. While, as we have seen, surgeries can be usefully viewed as social prostheses, extending human capabilities and technologies in the habitus, these prosthetic interruptions produce ongoing painful corporeal experiences and social unease for some, if not many, surgical patients.
One of the core aims of this article, however, has been to theorize surgeries as productive breaches in embodied time-lines without positioning pre-surgical bodies as ‘intact’ and post-surgical bodies as ‘damaged’. If surgeries exist within the field – within society’s technological possibilities – then those possibilities are incorporated into the habitus and into the body’s potential forthcomings at any given moment. This, at least, subverts the ‘before’ and ‘after’ binary of the pre- and post-surgical body. The key assertion in this article is therefore that power and time are intimately bound up in surgery’s social effects. Following Freeman, temporalities are the means by which social and institutional norms of gender become reified on DSD-affected bodies, as ‘somatic facts’. To put it more specifically, surgeries produce empowered or disempowered outcomes precisely through their connections with different temporal concepts and trajectories. The ethical effects of surgical procedures are connected with the temporal stories we tell about, and inscribe on, our bodies. Likewise, bodily integrity is about how we understand and negotiate our own corporealized temporalities. Unravelling the ethical dilemmas that surgeries cause is fundamentally, therefore, a process of producing or retracing time.