Between the Pages: 'How the Clinic Made Gender' Explores Identity
Sandra Eder, Ph.D., is a historian of medicine, gender and sexuality who serves as an associate professor in the history department at the University of California, Berkeley. In her book, "How the Clinic Made Gender: The Medical History of a Transformative Idea" (University of Chicago Press, 2022), Eder tells the story of how the concept of gender was invented in the 1950s in the United States, how the terminology has been redefined over the decades and its diverse use today.
In this exclusive interview with Giddy, Eder spoke about the role physicians at Johns Hopkins University played in the development of gender, how post-World War II societal fears contributed to an emphasis on strict gender roles and the ongoing debate about who owns the idea of gender.
Editor's note: This interview has been edited for length and clarity.
Can you provide an overview of the difference between sex, gender and sexuality?
Eder: Today, we would generally say sex is a biological category based on reproductive, anatomical and genetic characteristics. Gender, on the other hand, is understood as socially constructed roles, behaviors, activities and/or attributes. When we speak about gender identity, we usually describe an individual's sense of being a man, woman or nonbinary. Sexuality refers to a person's sexual identity, attraction and activity.
Until the mid-20th century, these categories were often deeply entangled and conflated. And they still are today, as we see in current debates. My book, "How the Clinic Made Gender," tells the story of how the idea of gender as a separate category from sex was developed in the 1950s—and many are surprised this took place at a clinic at one of the country's most prominent hospitals.
How did physicians at Johns Hopkins 'invent' gender in U.S. medicine in the 1950s?
We need to go a few years further back to start this story. In the late 1940s, pediatric endocrinologist Lawson Wilkins was treating children with intersex traits at the Johns Hopkins Hospital and its affiliated Children's Hospital in Baltimore, Maryland. Intersex is a general term used for people born with a reproductive or sexual anatomy that does not fit the typical definitions of female or male. At the time, physicians would have used the now-outdated terminology of "pseudo-hermaphrodite."
Wilkins was not the first. Starting in the 19th century, physicians tried to determine the sex of these individuals based on their gonads and the hormones they produced. In reality, this determination was far from easy or clear-cut, and physicians increasingly took into account the sex that had been assigned at birth and in which the person was living, as well as their psychosexual identity.
Consequently, they tried to determine sex based on behavior and social outcome. Some of them thought it might be better for individuals with intersex traits to grow up in the sex that was better for their social adjustment, that fit their behavior. They increasingly took into account if these individuals identified and behaved as boy or girl or man or woman.
For an adult individual, that often meant maintaining the sex they were already living in, even if it contradicted their biological sex. Physicians were no longer looking for the "true" sex—that is, the biologically correct sex—but for the sex that gave children an outlook of a relatively normal life; a life in which they could be recognized as boy or girl, man or woman.
Wilkins' main focus in his clinical work was a condition called congenital adrenal hyperplasia [CAH]. CAH caused male-appearing genitals in genetically female children at birth and male appearance throughout life. Many of these girls were mistaken as boys at birth and lived in the male sex. At the time, Wilkins argued this was a good solution. He thought it would be easier for them to live as boys and men. In other words, he favored social functionality for sex assignments.
As Wilkins started treating these children with cortisone, two things happened. He now thought they should live as girls since cortisone would prevent them from looking masculine. But he also wanted to learn more about their psychological health and settle the question of how these children with XX chromosomes and male-appearing genitals should live: as boys or as girls.
Wilkins hired psychologist John Money and psychiatrist couple Joan and John Hampson to perform a study of children with intersex traits who visited his clinic. The team compared biological sex characteristics and the sex the child was being raised in with a new category they had termed: gender role. "Gender role" basically described for them—and I am quoting them here—"all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively."
Their comparison showed, they claimed, that in the majority of cases, children with intersex traits identified with the sex they were raised in regardless of anatomical contradictions. And they used cases of children with CAH, among others, to support their theory. Money even postulated that all children learned their gender role growing up and would adjust to either sex assigned at birth.
In other words, the researchers claimed that rather than being determined biologically, masculinity and femininity were learned in the course of growing up. However, there was a catch. In the case of children with intersex traits, they claimed that any ambiguity in appearance had to be removed. This meant that in order for children to learn their gender role and convincingly become a boy or a girl, their bodies had to be adjusted to the sex they were raised in.
In practice, this meant the Hopkins team insisted that genital surgery was, therefore, essential in helping children develop the gender role consistent with their assigned sex at birth. Their genital anatomy had to be fixed as early as possible.
This leaves us with a particular tension. On one hand, the sex/gender binary developed at the Johns Hopkins Hospital in the 1950s proposed gender roles were learned and independent of biology. On the other hand, they thought a person's gender role became fixed over time; well, actually, they claimed this happened in the first two years of life through a somewhat opaque process of imprinting in early childhood. Gender, they argued, ultimately became indelible.
How did the tensions of post-World War II America contribute to this emphasis on creating strict gender roles?
One can say the Hopkins concept of gender was a particularly American reformulation of sex. It emerged in a certain post-World War II moment among debates about how one could ensure and socially engineer the development of a particular kind of American personality. This meant focusing on raising children to become well-adjusted, democratic citizens.
Scientists, politicians and the public grew increasingly anxious about the proper upbringing of children within the nuclear family, especially by a loving mother who enforced appropriate gender roles. National concerns during the Cold War deeply shaped the tendency to endorse existing norms and boundaries, social adjustment to a cultural status quo and, consequently, binary sex roles. In a way, the 1950s formulation of gender role was an endorsement of social engineering that demanded individuals adjusted to and performed binary sex roles and behavior.
Ironically, this history shows that a focus on culture and environment could be as deterministic as a focus on biology. Even though the idea of gender was deeply environmentalist, it still relied on—and assigned merit to—stereotypical sex norms. Girls were meant to be caring, gentle and domestic, and aspiring to marriage and motherhood. Sexuality was part of this proper gender role development, and heterosexuality was a sign of proper adjustment to one's gender role.
How has the idea of gender transformed over the decades, and who has contributed to its transformation?
One of the things I show in the book is how gender was—and is—a dynamic category.
Depending on the particular problem it was utilized to solve, it delineated various relationships between nature and nurture, biology and culture. Ideas transform over time and change within different contexts, which is exactly what happens to gender.
We can say gender goes down different avenues. One such avenue is the set of recommendations for medical engagement with children with intersex traits that are developed hand in hand with the gender concept. The Hopkins model is referred to as the "optimum gender of rearing" model. It recommends assigning any of two sexes early, assuming that gender role will follow, and prescribes surgical procedures to make the genitals of infants and small children appear convincingly male or female.
This entailed, of course, that these genital operations were performed on children at an age when they were incapable of consent, and many only learned about their diagnosis and these procedures much later in adulthood. These protocols were basically unchallenged until the 1990s when intersex activists and their allies began challenging these unethical procedures.
Another avenue led to psychology. In the 1960s, psychologists, such as Robert Soller at UCLA, increasingly used the term gender identity rather than gender role to describe a person's innermost concept of self. In the late 1960s and early 1970s, we see gender identity clinics being established at many American hospitals to provide care for trans individuals.
Ideas transform over time and change within different contexts, which is exactly what happens to gender.
Physicians used the concept of sex, gender role and gender identity to develop medical theories and treatment guidelines for what they called "transsexuality" at the time. In doing so, physicians often relied on stereotypical gender roles that did not fully encompass the experience or desires of transgender patients.
Outside of medical institutions, we see how feminist activists, artists and the queer community increasingly use gender starting in the early 1970s. Members of the LGBTQ+ community early on sometimes used gender in combination with provocative terminology and questioned and queered traditional gender stereotypes. One example is drag performers who talk about mixing gender signals and confusing gender roles.
Feminists took the Hopkins findings to argue that if gender roles were learned, then they could also be unlearned or reconfigured. Women and girls could be boisterous, independent, play with cars, fall in love with other women and girls—and still be female. All these behaviors would have been deemed masculine in the Hopkins model and considered a failure of proper gender role adjustment.
By the late 1970s, gender became part of feminist debates and was increasingly scrutinized and redefined. In this way, gender became a feminist creation, increasingly separated from its clinical origins and, eventually, a term that we are all familiar with.
It is up to us all to fill it with meaning for the 21st century.
Why is telling the history of how U.S. medicine invented gender important?
There is an ongoing struggle about who owns the idea of gender, who may instill it with meaning, define its implications and judge its importance. For some, it is just a polite way to say sex, as evident in the surge of gender reveal parties which are, in reality, just a celebration of whether a child's genital sex appears to be male or female on a sonogram. Others fear that current theories and practices of gender carry radical implications. Such concerns are expressed in debates about public bathrooms or fears about the destruction of the nuclear family and proper binary gender roles.
To know gender's history and to acknowledge that current usage is diverse—that we do not always mean the same thing when we talk about gender—allow us to grapple with complex questions and their dilemmas rather than shutting them off or simplifying. Most important, gender matters because it is still a concept that organizes the world we live in. The history of gender I have laid out in my book shows that gender is constantly remade through medical, social, cultural, economic and political practices.