Hypospadias surgery in a West African context: The surgical (re-)construction of what?

The surgical context

Since the mid-1990s, a team of paediatric surgeons from a European university hospital collaborating with a renowned international NGO has travelled twice a year to West Africa. Over time, these surgical missions have become popular, because they offer quality surgical care and long-term follow-up. Every year, then, for five days, a minimum average of 160 patients (191 during my fieldwork) come to the consultation hours held at a local hospital for post-operative check-up or as new candidates for surgery. These patients come either on their own or with parents. Some of them will be rescheduled for pre-operative visits (eighty-one during my fieldwork), and most of these will be operated on during the remaining week dedicated to surgery per se (thirty-eight urogenital surgeries during my fieldwork). The surgical missions are specialised in the treatment of two main kinds of congenital malformations: cleft lips and palates and variations of sex development. In the latter case, most patients present with a condition called hypospadias in which the urethral opening is not located on the tip of the glans, although the consultations also deal with cases of undescended testes and intersex conditions with so-called ambiguous genitalia. The kinds of ‘birth defects’ for which patients seek treatment are directly related to the areas of competence of the surgeons involved in this medical project, who specialise either in craniofacial or in urogenital/visceral surgery. Hence, there is a strong ‘selection bias’ in the recruitment of patients, although some present with other (congenital or accidental) conditions such as extra digits or skin burns (managed by the craniofacial surgeons), or various visceral conditions (most often, these patients are transferred for surgery to one of the NGO’s partner hospitals in Europe; when the children return home, the urogenital surgeons conduct follow-ups during the missions).

The initial idea of bringing a social scientist into the field came from one of the senior urogenital surgeons, who acted as my contact person and my referee for the various institutions and actors involved in this medical project. She has participated in these surgical missions for a long time, and was interested in knowing more about the ways in which the children born with a variation of sex development and their parents experienced the whole situation. She wondered in particular whether African culture and representations of intersex made it possible for the concerned persons to live a better life than in the North. Both of us were particularly interested in the fact that none of the patients showing up at the consultations, including those with so-called ambiguous genitalia, had been treated in early infancy. African doctors, as mentioned above, tend to deplore such belated diagnosis and treatment, which they attribute to the lack of the latest technologies (see Gnassingbe et al., 2009), but also to people’s ignorance or poor awareness of intersex as a medical condition, i.e. as a congenital malformation rather than a ‘malediction’ (see for example Balde et al., 1999; Osifo and Amusan, 2009).

By contrast, cases of children growing up with ‘ambiguous genitalia’ have become extremely rare in the North since the 1950s. This is due to the treatment plan – also known as ‘optimal gender policy’ – outlined by John Money and colleagues at the Johns Hopkins Hospital, Boston (USA), which defined standard practices until the 2006 Consensus Statement (Lee et al., 2006). The birth of an intersex infant has long been considered in the North as a ‘social emergency’ requiring ‘urgent medical attention’ (AAP, 2000: 138): first of all, a battery of diagnostic tests to decide what the most appropriate gender might be; second, surgery to ‘correct’ the appearance of the external genitalia and remove the internal parts of the reproductive system (including the gonads) deemed ambiguous or ‘opposed’ to the assigned gender. The ‘surgical fix’ and the overall treatment plan were supposed to ensure the healthy psychosexual development of the child in his/her assigned gender (see Money, Hampson and Hampson, 1955a, 1955b; for critical discussion, see Kessler, 1990, 1998; Dreger, 1998, 1999; Fausto-Sterling, 2000: 30–114; Karkazis, 2008).

Since the late 1980s, however, intersex adults and activists have critiqued the management philosophy inherited from Money and his colleagues as normalising medicine that exposes children to repeated clinical exams, unwanted genital surgeries, lifelong hormone replacement therapy, medical and family secrecy, shame and trauma, and gender-stereotypical education. After a decade of intersex activism to halt routine genital surgery in early infancy, some health care professionals began to express their doubts and reservations about past practices. ⁴ It is in this controversial context that my contact paediatric surgeon started questioning the necessity and benefits of sex assignment surgeries in early infancy. In practice, she stopped performing these some eight years ago, and, gradually, so did her colleagues at her home hospital. At present, these surgeons agree that it is best to let children decide for themselves about the opportunity and timing of genital surgery when they are older. At the same time, while they now agree not to perform any surgical act that is irreversible and detrimental to the patient (typically clitoris reductions), they do sometimes operate for so-called prophylactic reasons in specific situations (e.g., the ablation of non-functional and undescended testes to manage precancerous risks), although not without reservation and uncertainty. ⁵ Further, and in a more systematic manner, they continue to perform hypospadias surgery both at home – at an average frequency of one operation per week, they told me – and at the surgical missions in West Africa. Some of them readily acknowledge that the rationale behind such surgery is not always or simply functional but also cosmetic, even normalising. They do it all the same, in order, they state, to protect the child from teasing, psychological suffering, and stigmatisation and to enable him to urinate standing, to undress and shower in the locker rooms, and eventually engage in (hetero)sexual intercourse without shame or discomfort; in short, to support the child’s overall development and enhance the quality of his life.

(Non-)surgical scripts as social scripts

With the notable exception of parental distress – unmentioned above – these are the same core arguments that have been used since the mid-1950s to rationalise the now controversial optimal gender policy and the necessity of surgically normalising the appearance of genitalia. The paradox is only too apparent. First of all, it should be underscored that, in the context of these missions today, ⁶ to perform or not to perform genital surgery is not in question. As stated earlier, sex assignment surgery is never performed; surgery in the many cases of hypospadias almost always is. Further, both kinds of surgery aim to normalise genital appearance, are irreversible and are generally performed before the child can participate in the decision. ⁷ It seems, however, that there is normalising and normalising. When the surgical act seeks to do gender identity by operating on sex itself, i.e. to ‘boy’ or ‘girl’ a newborn whose genital morphology is, medically speaking, considered neither male nor female as in the case of sex assignment surgeries, then the surgeons who promote ‘less cutting and more talking’ are anxious that they might surgically assign the wrong gender identity. The risk of making such a mistake is minimised, by contrast, in the case of hypospadias surgeries. When the diagnosis excludes a more severe underlying intersex condition, ⁸ operations to normalise the appearance of the penis seek to provide the boy with better-looking ‘genital means’, as it were, so that the boy will be able to perform male-typical gender conducts such as urinating in a standing position.

In sum, the crucial difference seems to come down to the fact that sex assignment surgeries engineer boys and girls, whereas hypospadias surgeries enhance the boys’ own physical and psychological capabilities to perform ‘boyness’ according to proper hetero-masculinity. In what follows, I focus my discussion on the concrete ways in which the desirability of male gender and heterosexuality enhancing hypospadias surgeries commits the different actors encountered in my fieldwork to what I call a surgical script. In contrast, let me just suggest here that the possibility of surgically engineering a subject of sex, gender and sexuality de novo, so to speak, by operating on ‘ambiguous genitalia’ is made undesirable through a non-surgical script authored in part by the same surgeons promoting ‘less cutting and more talking’.

Surgical (and non-surgical) scripts are, of course, social scripts in the rich sociological sense John H. Gagnon and William Simon ([1973] 2005) wanted for their concept of ‘sexual scripts’. I do not mean, however, to apply the scripting theory of sexuality to intersex. ⁹ The analytical purpose of examining what is going on in the context of these surgical missions in terms of (non-)surgical scripts is to highlight the work of framing and meaning-making by the different actors: what are the terms in which they define hypospadiac conditions as problematic and problematic for whom? How is genital surgery rationalised as a treatment for hypospadias? What is it that surgeons agree to surgically treat in such cases? How do morphological ideals of sex, gender and heterosexuality, but also knowledge-practices such as clinical examination, co-produce the actors’ appreciation of the need for genital surgery?

For those of us concerned with the utility of a social scientific approach to the clinical management of intersex, the notion of script may present the further advantage of being used by health care professionals themselves for training purposes in order to improve surgical skills or clinical reasoning in patient-doctor encounters, or even to understand lay knowledge about illness. ¹⁰ It is therefore my hope that a social scientific analysis of (non-)surgical scripts can speak more directly to the health care professionals interested in using insights from the social sciences and the humanities to reflect critically on their own practices and on the ways in which we could, should, deal differently with intersex.

The surgical script: Hypospadias repair

During my fieldwork, hypospadiac conditions constituted about 60 per cent of the total 191 patients seen during consultations (cleft lips and palates included). Among the eighty-one patients later considered for surgery, thirty-eight were operated on by the urogenital surgeons – the majority for ‘hypospadias repair’ to use the surgeons’ term. Hypospadias is a generic notion for various conditions in which the meatus, i.e. the urethral opening, is not located on the tip of the glans but on the underside of the penis. The lower the meatus, the more ‘severe’ the condition is said to be. If the meatus is close to the scrotum or perineum, the penis may become curved downwards and its base hidden in the abdomen, sometimes along with undescended testes (cryptorchidism).

As far as I could tell, no hypospadias is ever ‘discovered’ at the consultations. The surgeons know the patient’s condition in advance as indicated on the waiting list prepared by the hospital or NGO staff in charge of recruiting the patients; most often, a local doctor has diagnosed the child and provided the parents with a referral to the surgical missions. ¹¹ If the boy is a new candidate for hypospadias repair, the task of the surgeons is to make a more precise diagnosis and discuss the timing, sometimes the opportunity, of surgery with the parents. If the boy has already been operated on, the question is then to assess the surgical results and the possible need for additional surgery in order to repair urethral stenosis (i.e. strictures) and/or suture the frequent urethral fistulas, i.e. orifices forming post-operatively through which urine passes. In addition to anamnesis and physical examination of the genitalia (penis and scrotum), the clinical examination includes asking the boy to urinate standing, so that surgeons can look at the direction of the jet and whether urine sprays over the child’s shoes. The object and purpose of the medical gaze is clearly normative: they want to assess the extent to which the boy is (un)able to perform boyness tidily. In a symptomatic manner, when urine sprays downwards, the surgeons attribute the problem to the hypospadiac condition or to the fistulas resulting from surgery, and not to the standing position – a gender requirement that, one could argue, makes it difficult even for non-hypospadiac boys and men not to mess their shoes or the toilet seat. In the very severe forms of hypospadias, i.e. when the meatal position is scrotal or close to the perineum, the boy is not asked to urinate. The surgeons already know he would fail the masculinity test, since the condition makes him ‘pee like a girl’ as some mothers put it. ¹²

Most of the time, mothers do not really need to elaborate on the reasons for their visit, even less to argue for surgery. The consultations are primarily a space in which the surgeons operationalise an already existing surgical script for hypospadias. They teach it to parents and patients, to the health professionals and the NGO staff who attend the consultations, but also to the interns, who have come along from their home hospital. They do this when they examine the genitalia and specify the diagnosis out loud so that it can be recorded in the patient’s file; when they ask the boy to urinate in a standing position; when they (sometimes) inquire into the parents’ and boy’s feelings and concerns, including about other children’s reactions to the boy’s condition; when they explain the diagnosis, the surgical treatment and post-operative results along with the possible complications (in particular, fistulas). They socialise in this manner all the protagonists – parents, patients, the local medical and NGO staff, their own interns – to the surgical script for hypospadias, thereby naturalising the rationale behind surgery, which is to operationalise a gender script. Indeed, and as earlier suggested, the surgical script frames hypospadias as a gender disability, rationalising the need for surgery as a treatment to enhance the boy’s own ability to do male gender. Further, the surgical script operates as a social script not just for gender-typical conducts; it is also and fundamentally a heteronormative script. While hypospadiac conditions do not fundamentally destabilise the socially sanctioned alignment between sex and gender identity, it seems that the child’s physical and psychological capacities to perform both gender-typical and heterosexual conducts need to be morphologically secured. Again, this normative dimension appears most clearly when the hypospadiac condition involves a penile curvature that would complicate vaginal penetration and insemination. The purpose of surgery is then to straighten the penis to facilitate coitus and to advance the meatal position, so that he can ejaculate into the vagina. ¹³

Given the current surgical script for hypospadias, parents and patients do not need to make explicit their desire for gender and heterosexual conformity through appearance-normalising surgery. They did express it during research interviews, when I asked about the reasons for their visit, their concerns and expectations. In the very severe cases of hypospadias, especially when the boy had to ‘pee like a girl’, mothers were concerned about his (dis)ability to signify masculinity in front of his peers and to the community at large. They always also worried a lot about his entry into sexuality, and, perhaps even more, about his reproductive capabilities. The patients who were interviewed expressed the same concerns. In terms of expectations, both parents and patients considered surgery a desirable and efficient treatment capable of consolidating virility/masculinity, of making the concerned person into ‘a real man’ as some patients put it, and of making it possible to have coital sex and to procreate. In sum, they all wanted for their sons or for themselves ¹⁴ the normalised penis – and, by metonymic extension, the normal sexual and psychosocial life as a normal boy/man – promised in the surgical script for hypospadias.

Revisions in the surgical script

The surgeons I encountered in my fieldwork use three main surgical techniques, depending on where the meatus is located: a MAGPI (meatal advancement and glanduloplasty) when the meatus is on the glans or close to the corona; a Duplay-Snodgrass (named after the surgeons who developed this procedure), when it is positioned between the corona and the anterior mid-part of the penis; a Bracka (as previous), when it is located in the posterior mid-part, i.e. further down towards the scrotum or perineum. The Bracka procedure involves two steps: first, buccal tissue from the inner lower lip is grafted along the ventral part of the penis; if the graft takes and looks good at the following consultation, the surgeons will use it to make the urethral tube and advance the meatus toward the tip of the penis (for more details on these procedures, see Hadidi and Azmy, 2004). All of the many existing techniques (more than 150 in the mid-1990s) aim to position the meatus as close as possible to the tip of the glans and, in the case of penile curvature, to make a straight penis (see for example Fichtner et al., 1995: 833).

At the operating theatre, the surgeons (seniors and interns), the anaesthesiologists (doctors and nurses) and the operating room nurses or technicians are from the North. The local medical staff assists the Northern team during the interventions and especially post-operatively, taking care of the patients as they wake up. Doctors and/or surgeons from the local hospital or visiting from other, sometimes distant, areas, observe the operations to update their know-how and learn any new tricks of the art. Paediatric surgery, even less paediatric anaesthesia, is not taught in most West African countries. Surgery, especially paediatric surgery, is thus no routine practice; it remains a life-threatening situation and it is not rare that patients die during surgery. The operating room ‘solid’ equipment (tables, lights, anaesthetising devices, etc.) and the sterilising facilities are available at the local hospital. All the ‘soft’ and disposable material (surgical threads, compresses, disinfectants, gloves, etc.) needed for surgery is obtained through public and private sponsors and shipped from Europe to complete the stock left from previous missions (which includes the basic kit of scalpels). The Northern surgeons bring their own surgical goggles and sometimes other high-tech portable devices for specific operations.

As a first step, the senior surgeon in charge of the urogenital operations at the time of my fieldwork, aided by one intern, always began by reassessing the accuracy of the surgical planning established during the pre-operative consultations. This is standard practice, since hypospadiac conditions can be better examined when the patient is under anaesthesia (see for example Marrocco, 2004: 202). In light of this new evaluation, the surgeon tended to perform a less heavy surgery than planned, swapping, in all cases of severe hypospadias I witnessed, the two-step Bracka procedure for a one-stage surgery (a Duplay-Snodgrass). The surgeon’s decision to perform a less complicated procedure compromised the sought-for result of hypospadias surgery (see Fichtner et al., 1995: 833). In practice, this meant positioning the meatus lower on the glans, sometimes closer to its base (at the corona), but never on its tip, thereby failing to achieve the cosmetic ideal promoted in the North through a rhetoric of technical progress:

[…] there have been important advances during the past 30 years, and the result now obtained would be the envy of older surgeons. It is instructive to note that particular attention is now given to securing a meatus at the tip of the glans (even in those minor degrees of hypospadias which would formerly have been left untreated), reflecting the pursuit of physical perfection which now fuels the popularity of cosmetic surgery. (Sir David Innes Williams in his foreword to Hadidi and Azmy, 2004: vii; emphasis added)

The surgeons’ practices at the missions offer an interesting contrast. They tend to go for less involved surgeries, with the ‘imperfect’ result that the meatus will not be positioned on the tip of the glans. This tendency is not a function of the severity of the hypospadias, but is observable more generally in their case management of all such conditions. Indeed, the surgeons do not treat ‘those minor degrees of hypospadias which would formerly have been left untreated’, but are now treated in the North. Typically, they do not offer to perform hypospadias surgery when the meatal position is on the glans, but not on its tip (i.e. glandular hypospadias) – hence leaving more patients with a ‘misplaced’ meatus. One can here wonder why parents bring their boys to the surgical missions, especially when, in a few cases, it turned out during the consultations that they were in fact not worried by the ‘misplaced’ meatus. It makes sense to argue that they would not have come on their own (see also Mureau, 1996: 705). They came most probably because a local doctor correctly diagnosed the hypospadiac condition and referred them to the ‘White surgeons’. Again, this draws our attention to the fact that the opportunity of surgery is always already implicated in the diagnosis of hypospadias, as an effect of the prevailing surgical script. The surgeons do not either propose repairing those very minor forms of hypospadias when the foreskin is not entirely fused. They do, however, propose and perform circumcision; the need for medical circumcision – instead of ‘ritual circumcision’ as the local actors name it – is often the only reason why such patients come to the consultations.

On-the-cheap surgery?

The reasons why the surgeons revise in this manner the indications for meatal advancement surgery and do not treat surgically minor forms of hypospadias are of course context-dependent. Although they are clearly committed to performing the same surgical procedures regardless of the context, using imported material during the operations to this end, they are also aware of the need to adapt their practices both to the poorer socio-material conditions for surgical care in West Africa, and to the schedule of the missions that prevents them following up patients as closely and frequently as they would at their home hospital. The fact that all the protagonists tend to deplore the local surgical situation in terms of technological lack and material deprivation raises the disturbing question of whether the Northern surgeons may have to practise ‘on-the-cheap’ surgery on their West African patients. I suggest here that there is indeed a ‘double standard’ at work. However, this double standard does not reflect a two-tier surgery, but rather the fact that the poorer socio-material conditions in West Africa bring the surgeons to adjust the indications for hypospadias surgery. To be more precise, while they do operationalise the prevailing surgical script, as earlier discussed, they also rewrite it in part. When they do not absolutely seek to advance the meatus to the tip of the glans or decide not to operate on minor forms of hypospadias, they revise in practice the very definition of a normal meatal position, and thus the very distinction between a normal and a hypospadiac penis.

From the surgeons’ perspective, the reasons for these revisions are entirely pragmatic. They reflect a down-to-earth response to the local conditions of (im-)possibility to operationalise the prevailing surgical script for hypospadias at the missions rather than, say, an explicitly reformist critique of the normalising purposes of such surgery. In this regard, one could argue that they here fail to see their opposition to sex assignment surgeries through to the end. But their actual surgical practices are somehow ahead of their clinical reasoning. Most importantly, these practices are in fact perfectly consistent with existing alternative standards for hypospadias surgery, as outlined in a well-known German study of 500 ‘normal’ men documenting that only 55 per cent of them had the meatus positioned at the tip of the glans, while the other 45 per cent did not (Fichtner et al., 1995). In this light, the authors rightly point out that ‘it remains unclear whether the tip of the glans truly is the normal site’ (Fichtner et al., 1995: 833). This study and the significance of a 45 per cent incidence rate of normal variations in meatal positions have been discussed from a social science perspective by various authors to highlight the constitutive exclusions supporting the medical conception of penile normality (see Dreger, 1998; Kessler, 1998; Morland, 2005; Karkazis, 2008). For my part, I am even more interested in the fact that the surgeons who authored that study changed their practices accordingly, by narrowing the prevailing surgical indications for meatal advancement, thereby defining new recommendations for the surgical management of hypospadiac conditions:

Pediatric urologists should be aware of the observed ‘normal distribution’ of meatal positions in men since the aim of reconstructive surgery should be to restore the individual to normal. However, pure esthetic surgery would try to surpass the normal. It appears from our study that this is the case in many patients with hypospadias in whom the surgeon attempts to place the meatus in a position where it would not be found in 45% of so-called normal men. […] Our data have led us to narrow our indication for meatal advancement in children with anterior hypospadias. In reconstructive surgery of more severe hypospadias […] we do not insist on advancing the meatus beyond the corona in all instances when it is not easily feasible. This strategy may reduce complications associated with glans plasty and meatal advancement without impairing functional and cosmetic results. (Fichtner et al., 1995: 834, emphases added)

As surgeons define, and apply, more restrictive than the state-of-the-art cosmetic indications, they actively produce a double standard in the sense of a practical alternative to the prevailing surgical script for hypospadias. At the same time, the new recommendations for meatal advancement surgery do not touch upon the social script for male-typical conducts and reproductive heterosexuality. In this regard, the revised script operationalised by the German team and the surgeons at the missions in West Africa continues to enforce, as earlier discussed, the heteronormative rationale behind hypospadias repair. Still, it is interesting to note that hetero-normalising surgery – compared to simple refusal of it – can also be diversity-affirming, insofar as the surgeons’ actual practices seek more (the authors-surgeons of the German study) or less (the surgeons at the missions) explicitly to re-qualify as perfectly normal meatal positions that are not on the tip of the glans.

Further, and most importantly, the revised surgical script for hypospadias is of great interest, not to say benefit, to the patients themselves. In the above quote, the German surgeons also argue that narrower indications for meatal advancement surgery may reduce the complications inherent to such surgery, and the reason why most hypospadias repair consists in fact in repairing hypospadias repair. The most frequent complications associated with hypospadias surgery are urethral fistulas (see for example Marrocco et al., 2004). The closer the surgeons seek to advance the meatus toward the tip of the glans, the higher the risks that fistulas appear on the urethral tubal part (re-)constructed to this end. Although the surgeons at the missions were not able to articulate a precise rate, fistulas reportedly appeared more systematically and frequently in the West African context than in their home hospital where, they told me, they managed to lower that rate to less than 4 to 5 per cent over the years. Again, this difference in surgical outcomes is context-dependent, and, according to the surgeons, maybe related to the fact that the patients at the missions are seen and operated on at an older age than in the North (see note 7 above). Interestingly, the only time the surgeons resort to a clinical – rather than just pragmatic – reasoning for their practices is precisely here: their revised indications for meatal advancement surgery translate their explicit efforts to control the observable higher rate of post-operative fistulas in their West African patients. ¹⁵

The surgical (re-)construction of what?

The practice of a hetero-normalising surgery that is simultaneously diversity-affirming brings into new critical focus two major problematic assumptions that underwrite both the prevailing surgical script for hypospadias and the revised version of it, except that it shows more clearly in the latter. The above quote from the German study is again instructive in this regard. The authors defend the practice of narrowing the surgical indications for meatal advancement in the unspoken name of naïve realism, assuming that such indications reflect more truly the natural state of penises, penises-as-they-really-are, i.e. with a great variety of meatal positions. The problem with naïve realism – in the sense of premature or unconstructed realism (Bachelard, [1938] 2002) – is, of course, that there is no such thing as penile normality. There is not even something like a penis to begin with, independently from the knowledge-practices that make it an object of intense scrutiny, preoccupation and intervention, that oppose it to the ‘opposite’ sex and further invest it with all sorts of significantly non-penile but clearly male gender and sexuality-related meanings, attributions and prescriptions. Whether the definition of what counts as penile normality is more or less inclusive of the so-called normal variations in meatal positions makes no difference in this matter. The problem remains as before.

At this point, it is worth mentioning that (almost) all intersex activists or adults opposing early genital surgery, and most of their allies, assume the same naïve realism about the existence of a biological continuum between the two sexes or of normal developmental variations. While intersex associations have operated from their beginning with a biological definition of intersex as a nature-made variance, ¹⁶ this tendency has become, it seems, even stronger (see for example Diamond and Beh, 2006; Hinkle, 2006) in response to the Consensus Statement that proposed renaming hermaphroditism ‘disorders of sex development’ (see Lee et al., 2006). One understands that intersex associations opposing the new medical terminology – such as the UK Androgen Insensitivity Syndrome Support Group, Organisation Intersex International and the German Association of Intersexed People (Verein Intersexuelle Menschen) – seek to promote the appealing idea that ‘nature loves diversity, [but] society hates it’ ¹⁷ in order to depathologise their bodies, themselves. I have discussed elsewhere why we should not simply presume, as most feminist-inspired critiques of science do, that the notion of biological variation – or other variations on this biological theme (e.g., biological continuum, brain plasticity) – innocently advances strategic/critical engagements with the biology of sex (see for example Kraus, 2012). For the present argument, I simply want to stress the fact that the philosophical question of naïve realism – in other words, of substance, here the substance of sex ¹⁸ – as unearthly as it may seem compared to the real-world struggles over the revised guidelines for standards of care and the very definition of intersex, is all the more important to address precisely for these reasons and, further, to do so (as I try here) in relation to partial but promising changes in actual surgical practices.

For those who take for granted the prevailing or revised surgical script for hypospadias, or more generally the hetero-normalising rationale behind any genital surgery, their ontological commitment to naïve realism is intrinsically linked to another problematic assumption, which I call naïve surgical (re-)constructionism to refer to the conviction that surgery can (re-)construct normal-looking genitalia. However, and to paraphrase the German study, it remains unclear not only ‘whether the tip of the glans truly is the normal site’ (Fichtner et al., 1995: 833) but also whether penile normality (even in the inclusive sense given by these authors) and, as an extension genital normality, is truly achieved through surgery. The answer from a group of Dutch paediatric specialists and authors of a comparative study about ‘Genital perception of children, adolescents, and adults operated on for hypospadias’ is resolutely negative: ‘hypospadias surgery never produces a perfectly normal penile appearance’ (Mureau et al., 1995: 290). They even warn the surgeons against the temptation to claim to the contrary:

Boys who have been told that their penis will be ‘normal’ after surgery could be very disappointed with the cosmetic result. The boys’ wish to have a penile appearance similar to other boys’ is not fulfilled after correction, which might lead to disappointment about and fixation on their penile appearance. (Mureau et al., 1995: 291)

In her pioneering book, Lessons from the Intersexed (1998), social psychologist Suzanne Kessler argues that what genital surgery truly achieves is ‘the idea of genitals’ more than anything else (Kessler, 1998: 118; emphasis added). In fact, Kessler’s argument extends the German surgeons’ objections to the surgical pursuit of physical perfection (see Fichtner et al., 1995). Let us recall that the latter do not oppose cosmetic surgery or surgical hetero-normalisation per se, but the excessive practice of seeking to make the penis look ‘better than normal’. This means that surgery is actually able to realise the unrealistic idea that all meatus are positioned on the tip of the glans. According to them, and in view of the existing normal variations in meatal positions, this idea is better understood as a cosmetic ideal rather than a morphological reality. Kessler generalises this claim. The problem is not just with the fact that state-of-the-art cosmetic surgery realises ideal genitalia, i.e. genitalia that look better than normal. She wants to argue that even a more ‘realistic’ surgery always already realises genital ideals, i.e. normative morphological ideals of genitalia – the ‘idea of genitals’ to use her own terms.

Iain Morland, an intersex scholar, pushes the argument one step further. As I read him, Morland displaces the critical focus from the question of genital ideal-typicality to the kind of action performed through surgery: in what sense can we consider that the operated genitalia are successfully sexed and, further, (re-)constructed after the morphological ideals of genital sex? At stake here is the idea – persisting in the German study and in Kessler’s discussion – that surgery is efficient in making real ‘unreal’ genitals in the sense earlier discussed of ideal genitals or genital ideals/the ‘idea of genitals’. In the German study, this feat can be achieved successfully, even if cosmetic ideals are said to be excessive. To the contrary, Morland argues that genital surgery is a kind of doing characterised by failure, when it comes to realising sexed genitalia after genital ideals: operations do many things to the patients except normalising the appearance of their atypical genitalia (see also Mureau et al., 1995, quoted above). What surgery does, and in a more successful manner, is to construct the morphological ideals of genital sex retroactively; indeed to re-construct them after the fact, i.e. after the ways in which the genitalia appear as a result of genital surgery (see Morland, 2005: 339). In sum, the realistic trick of naïve surgical (re-)constructionism amounts to this: genital ideals are derived from the morphological appearance of operated – rather than non-operated – genitalia; yet surgery is supposed to have realised these ideals after existing ‘normal’-looking genitalia, so that the post-operative morphological ideals of genital sex do not appear as such, but as true reflections of non-operated genitalia.

This casts a new light on the Northern surgeons’ failure to meet the state-of-the-art cosmetic standards of hypospadias repair in the context of the surgical missions in West Africa. Indeed, failure, I suggest, is more the rule than an exception in surgical practices, including in a Northern high-tech surgical context. Not unlike Morland, I here follow in part feminist philosopher, Judith Butler, when she argues that the forceful embodiment of the morphological ideals for a proper subject of sex, gender and desire is bound to a certain degree of performative unhappiness, i.e. to constitutive failures, as these ideals are never embodied to the perfection; and this is true for all of us regardless of our native morphology (see Butler, 1990, 1993). At the same time, I think Morland’s focus on genital surgery enriches Butler’s discussion and, more generally, the existing feminist/queer-inspired literature on intersex with a crucial insight: that the genital ideals governing surgeons’ practices are actively produced through and are an effect of the ‘surgical fix’ itself. To make the point even more strongly, we could here argue for the centrality and logical precedence of genital surgery in the production of genital ideals. This means that surgery does not only actualise such ideals, even less literalise, exemplify or reveal in a paradigmatic manner the forceful but imperfect ways in which intersex and non-intersex persons alike come to embody them. Ultimately, genital surgery stands out, I suggest, as the definiens and the morphological ideals of genital sex as the definiendum. This means that surgical operations on intersex do sex in a highly distinctive manner: they fundamentally serve to define and produce the very ‘idea of genitals’.

Conclusion

In this article, I have sought to analyse the concrete ways in which what I have called the surgical script for hypospadias is operationalised in the context of surgical missions in West Africa, committing the various actors to desire (parents and patients), promote (the Northern team, the local medical and NGO staff), and perform (the Northern surgeons) hypospadias surgeries. At the same time, I have also shown that the local conditions of (im-)possibility for paediatric surgical care in this particular context brought the Northern surgeons to rewrite the prevailing surgical script, revising in practice the very definition of penile normality and the textbook standards for hypospadias repair. In this manner, they materialise the possibility of changing the existing surgical practices and, as an extension, the current framework for the clinical management of intersex, although – or rather because – they fail to meet the state-of-the-art cosmetic standards for hetero-normalising genital surgery. Both possibility and failure are context-dependent. However, they are less a function of the technological lack and material deprivation deplored by all the protagonists than of the kind of action performed through genital surgery. First of all, surgery never succeeds in normalising the appearance of intersex genitalia. Further, and most importantly, what counts as genital normality turns out to be a normative ideal re-constructed post-operatively, highlighting the fact that the reference norm for the very ‘idea of genitals’ is actively produced through such surgery and derived from the morphological appearance of the operated genitalia. Fieldwork and critical focus on what surgeons do in practice are here of great value to make tangible this theoretical point, and contribute to feminist/queer-inspired discussions about the performative modes through which bodies come to matter through the reiteration of morphological norms for genital sex. At the missions in West Africa, such a process of reiteration becomes particularly salient when the Northern surgeons rewrite the prevailing surgical script for hypospadias. The ways in which they revise in practice what counts as penile normality, as they tend to go for less complicated but more diversity-affirming surgeries, provide a most telling instance of the productive power of genital surgery itself to define, and sometimes redefine, the very ‘idea of genitals’ and the genital-centred morphological ideals of sex, gender, and reproductive heterosexuality.