This book is like a novel with an unreliable narrator. Zoë Playdon assembles a great deal of interesting and important material but she has an agenda which leads her into various kinds of prolepsis: we get the verdict before the evidence and - like the headline writers at Pink News - Playdon can never resist a judgmental adjective, as if she fears readers will reach incorrect conclusions without them. The trouble with such intrusive prolepsis is that some readers will conclude that you protest too much, that you are less confident of your conclusions than you would like us to believe.
The larger narrative of the book offers a background survey of a hundred years’ worth of medical and legal theory and practice around questions of intersex and trans sex, much of which was new to me and which is interesting in its own right. But the core narrative is the story of a Scottish aristocrat and medical doctor, Ewan Forbes, born Elisabeth Forbes in 1912 and who became 11th Baronet of Forbes but only after a 1966 legal challenge to his claim, brought on the grounds that he was female not male and thus disqualified from the baronetcy by laws of primogeniture.
I will try to focus what I think is the main issue. Birth certificates, universally so, at least until recently, require that all newborns be classified by sex as either Male or Female. It’s also known, not least by midwives, that some babies show sexually ambiguous characteristics which may or may not tend to resolve (and then, more or less) into Male or Female over time. But there is no category on the birth certificate (such as “To be confirmed”) to allow for this - a fact which has proved very acceptable to nearly all parents, the great upholders of binary life, who simply want an uncomplicated Boy or Girl. It’s also known that there are invisible sexual ambiguities which will only show up on later and more thorough examination. The standard birth certificate inevitably forces a small number of square pegs into round holes, and vice versa, really quite unnecessarily.
It’s also known that there are communities without benefit of sex clinics, gender identity theorists, education, money, or friends in high places, where there is a higher than average incidence of ambiguity which then partially resolves itself at puberty without the intervention of anything except the passage of time. The best-known case is that of a community in the Dominican Republic where some (provisionally) F children become anatomically much more like M children in the course of puberty. This is a sufficiently common occurrence for there to be a name for those affected: guevedoces which means penises at (age) twelve: see https://en.wikipedia.org/wiki/Guevedoce. It’s true, these F to M children retain some distinctive characteristics: they never go bald and they do not suffer from the common M problem of enlarged prostates - they do have prostates, but small ones. Both of those facts attracted the attention of Big Pharma which has developed hormone treatments for baldness and prostate enlargement based on genetic profiles of these rural children. They most commonly go under the name of the drug Finasteride which can have unpleasant psychological side-effects.
So here we have a well-studied case of spontaneous transition without chemical or surgical intervention in relation to individuals who would, in consequence, generally be classed as intersex (the old hermaphrodite). The original research was done in the 1970s by Dr Julianne Imperato-McGinley. Playdon does not mention it anywhere in her book though it strikes me as very pertinent to the earlier part of her discussion.
Ewan Forbes, the subject of the book, was classified as F on the original 1912 birth certificate and named Elisabeth but very early in life showed tomboyish gender characteristics which were very noticeable. When Elisabeth’s mother examined her child at the age of six she satisfied herself that the child “had a normal female anatomy, and later, she warned him that he might menstruate” (p 18) - though at that time the onset of menstruation would normally occur much later than it now does. As it turned out, at the age of sixteen Ewan “began to have erections and emissions” (his words, p. 23).
When he was fifteen, his educated , wealthy and well-connected mother had taken him on a tour of 1920s European sex clinics where he was treated with hormone injections (p.23), presumably of testosterone or something similar. All the medical records have been lost. Playdon later comments that this treatment “meant that he did not go through the wrong puberty” (p.46).
Put baldly like that, it looks to me like a case of the fallacy, post hoc ergo propter hoc (After that, therefore because of that). Are we supposed to believe that between the ages of fifteen and sixteen Ewan acquired something capable of “erections” as a result of hormone injections? And “emissions” which would imply the presence of prostate and testes unless the emissions were what would now be called female ejaculation? (Playdon thinks they were and she seems obviously right: see p 185).
Is it not much more likely that mother and son were aware of (belated? continuing?) pubertal changes of an M character occurring before they set off for the sex clinics and that the injections aided a development that had already begun rather than caused it? If so, Ewan would have a lot in common with the Dominican Republic intersex children.
However, later in the book Ewan’s sister Margaret is reported as writing of Ewan that “She had her periods regularly just like every other girl” (p 132) but this was written in a context of personal hostility and is almost certainly untrue. (Upper class people have no problems about lying when it suits them and there is more to come).
When in the context of the contested baronetcy Ewan is medically examined by Edinburgh university Professor Strong at the end of 1966, he is found to have a vagina and a urethra separate from and behind what the medical report describes as a “virilised clitoris” (phallus) which would be regarded as “greatly enlarged” if thought of as a clitoris and “abnormally small” as a penis. Breast development “more resembled the female pattern than the male” - all this at pages 150-151. On this basis, Strong diagnoses a case of female pseudo-hermaphroditism, then a standard category which explained male characteristics by the presence of masculinising hormones in the womb. Ewan is a person who did not really fit into the birth certificate M and F boxes and so the original box ticked was an instance of deeming rather than simple categorisation. Ewan had successfully applied for a retrospective change to the box back in 1950, using medical reports kindly supplied by friends and colleagues and quite possibly suspect as simple favours. But without a great deal of difficulty, he became Ewan not Elisabeth, M not F, and announced the fact with a small ad. in the local newspaper.
Playdon objects to Strong’s diagnosis on the basis that Ewan had begun taking testosterone as a teenager and continued to take it into adult life, it seems regularly. As a result, Playdon reckons that his 1966 male characteristics are more likely to have arisen from long use of testosterone than from womb facts. In other words, Playdon thinks Ewan is trans in the modern sense rather than intersex. He had set out, originally in the 1920s, with the help of his mother and long before these things were fully theorised, to fit his female body to his sense of male self. In the 1966 legal and medical context, that story would have been less helpful to his claim to maleness than the intersex story, and thus a reason not to advance it. Ewan insisted on his physical and not just psychological maleness, now additionally evidenced by the sudden and miraculous appearance of a testicle - he faked the evidence.
When I read the word “testosterone” I always recall that I have a small bit of skin in the game and I will tell the story because it is also about cause and effect.
A feature of schools in my childhood was the annual medical examination by the School Doctor. Either in 1958 or 1959, when I was eleven or twelve (I think eleven), the School Doctor discovered that I had an undescended testicle. My mother, relaying the news to me, said that this had to be dealt with because it could cause problems later - she did not name them, but when much later I looked them up they were identified as cancer and infertility. The treatment would be a course of injections and, if that failed, then an operation. So once or twice a week, my mother took me on the bus to our local GP surgery where a very large syringe equipped with a long needle was pushed deep into my thigh; on one occasion the needle could not take the strain and broke.
A first course of injections partly worked and so it was decided to give me a second course, at the end of which it was deemed that my testicle had sufficiently descended. No one told me that these testosterone injections might have side-effects and so I lived a miserable pre-teen existence believing that my semi-permanent state of erection - permanent on bus rides - signified something wrong with me. I was troubled rather earlier in life than Ewan by erections and emissions.
Many years later, I had this thought: I was eleven or twelve. I was undersized and underweight and maybe a slow developer. Perhaps that testicle would have eventually descended of its own accord. Maybe the injections just helped it along.
Maybe something like that happened to Ewan Forbes who had begun some physical transition, involving the development of a phallus from a clitoris, before being helped along by testosterone or some other hormone used in 1920s Austrian and German sex clinics. They did not cause the transition; they assisted it.
This is important because Playdon wants to blur the distinction between inter sex and trans sex and subsume both into a single trans category.This seems a disservice to the small but important group of intersex-born people whose life trajectories are rather different to those of other trans people who often go through the “wrong” puberty with permanent consequences which means that they are not intersex in the traditional sense and that they have a more obvious quantum of characteristics which derive from long residence in their unambiguous birth sex - for example, in terms of bone, muscle and height.
Playdon believes and as an activist has committed herself to the view that the right way to proceed in all cases, intersex and trans sex, is from the individual’s own self-identification. Medical access to hormones and surgery should follow from that, where sought. This may well be the best way of looking at things, since several of the alternatives have proved pretty awful in their consequences, as Playdon elaborates. Doctors have their own weaknesses, and ambitious ones sometimes most of all.
However, it does not follow that self-identification is all that should be needed in the wider society. There are at least some grounds for thinking that some kind of regulation is necessary, which may vary according to context and so on. Playdon disagrees:
“…the only information about themselves that trans people - or anyone - are obliged to give in a social setting is their name and perhaps their pronouns” (page 308)
Well, at present name and pronoun won’t get you into a pub if you look sixteen; it won’t get you a free bus ride even if you look sixty five; it won’t get you access over the telephone to the state of your bank account; and so on. Unthinking maximalist demands, accompanied in the recent past by some fairly unpleasant behaviour, seem to express not so much a desire for equality as an excessive sense of entitlement. They have weakened the case transgender activists have been making and must be reckoned part cause of the more recent backlash: see, for example, Kathleen Stock's Material Girls, reviewed on this site on 24 October 2021.