How the Clinic Made Gender gives a detailed historical account of the role of clinical practices at the paediatric endocrinology clinic of Johns Hopkins Hospital, Baltimore, Maryland, in the mid-20th century, in shaping and redefining the concept of gender. Sandra Eder’s narrative style is very engaging and allows the reader to visualise the Hopkins clinic and develop a sense of familiarity with the people mentioned in the book. Although the author assumes that readers have a certain level of familiarity with medical practices, the book becomes less technical towards the end.
Eder demonstrates that the clinics were not just a place of treatment but also a space where ideas around gender were constructed. She sheds light on the conflicting and contradictory origin and evolution of the concept of gender, which emerged from the pragmatic concerns of clinicians treating children with intersex traits, as opposed to theoretical reflections. Eder, through this lens, provides an account of the history of how medical practitioners came to distinguish between sex and gender, while still reinforcing rigid binary gender norms.
This medical discourse of gender has evolved through the intersection of different distinct and overlapping discourses in the fields of endocrinology, psychiatry, psychology, and the social sciences. Thus, it becomes evident that the clinic played a pivotal role in “giving sex” and, by extension, “giving gender”. The doctors’ decisions about sex assignment were not just neutral medical choices; they were acts of power that shaped how individuals were allowed to exist within society. In many ways, Eder’s account aligns with Michel Foucault’s concepts of power and the medical gaze. Foucault’s notion of power, discipline, and the medicalisation of bodies provides a theoretical backdrop for understanding Eder’s work and vice versa. Both of them put forth the argument that institutions such as medical science through its power, constructs identities and enforces (and reinforce) societal norms on gender and sexuality. In the case of intersex and trans bodies, medical professionals act as gatekeepers who determine what kinds of bodies are “healthy” or “pathological”.
Eder focuses on the work of John Money, Lawson Wilkins, and Joan and John Hampson, who worked together at Johns Hopkins in the mid-20th century. Before the 1950s, doctors primarily focused on determining a patient’s biological sex based on factors such as chromosomes, gonads, and genital appearance. Gradually, clinicians began to shift away from this rigid approach by introducing the term “gender role” to describe how children learned to be boys or girls through socialisation. This marks a departure from the earlier understanding that gender was solely tied to biological sex and that children could grow up as boys or girls, regardless of their biological sex, as long as they were raised consistently in that gender. Eder traces this back to the influence of culturalist approaches that dominated social sciences which challenged the then-prevailing notions of scientific racism and biological determinism. While “gender role” challenged biological determinism, it also introduced a new kind of determinism rooted in social norms. Thus, gender became another site where social expectations — particularly regarding masculinity, femininity, and heterosexuality — were strictly enforced. Heterosexuality was seen as a sign of normal adjustment to one’s gender role. These cultural norms were rooted in white, middle-class ideas of masculinity and femininity defining what was considered a “correct” gender role. This also marks a shift towards the psychologisation of sex, where psychological well-being and social adjustment became important considerations in sex and gender assignment. This shift is contextualised within broader cultural and scientific changes, showing how gender became an important factor in medical diagnoses, treatments, and identity formation. Eder situates this medical history within the broader social context of postwar America. This period marked an increase in concerns about the psychological health and social adjustment of individuals. Growing influence of psychological theories on personality development and social engineering ideas contributed to this clinic’s approach to gender. Thus, we could see that the medical professionals at Johns Hopkins were not simply responding to biological anomalies, they were also attempting to address societal anxieties about gender roles, family dynamics, and social norms.
The book begins with the case of Charles, a child born with Congenital Adrenal Hyperplasia (CAH), a condition which results in a lack of cortisol and overproduction of androgen (p 1-3). Charles was assigned male because of his male-like physical appearance (virilised genitalia) at the time of birth. But after further medical examination including chromosomal testing, the doctors said that Charles had XX chromosomes and had ovaries. This indicated a biological female sex. The unit at the Hopkins hospital had discussions on whether to reassign Charles as female based on this chromosomal information, or to continue raising him as male. Their decision reflected a new clinical approach which prioritised gender role over biological factors like chromosomes or gonads. Charles was reassigned as female, and doctors believed that as long as he was consistently raised as a girl, he would adopt a female gender identity and role. Starting with Charles, the book provides numerous case studies of children with intersex traits and how physicians at Johns Hopkins Hospital used various factors and criteria to decide which gender should be assigned to them (Chapter 1, 2 and 4). These case studies illustrate the shift in medical approaches to CAH. Initially, doctors employed radical surgeries, including adrenalectomies, to manage CAH. The introduction of asepsis and anaesthesia made surgery more accessible and safer and enabled doctors to intervene in cases of ambiguous genitalia. But, with the advent of cortisone therapy, the focus of treatment shifted towards medical management, thereby reducing the need for invasive surgeries. Before cortisone, medical efforts were largely focused on keeping children with CAH alive. However, once cortisone treatment stabilised their health, the focus shifted to decisions about gender assignment.
The decision to assign a child to a particular sex was increasingly based not only on physical characteristics but also on assumptions about their future ability to live within the constraints of binary gender norms (Chapter 5 and 6). This focus on the child’s future social and psychological well-being marks an important shift toward the concept of “gender” as something distinct from biological sex. Eder also discusses the ethical concerns and criticisms that arose in later decades. The voices of the patients themselves and the families were often marginalised in the medical decision-making process, as doctors prioritised social conformity over the individual’s experiences. Many of the children treated under these protocols grew up to experience psychological distress, particularly when they discovered that irreversible surgeries had been performed on their bodies without their consent. Some patients rejected the gender assigned to them at birth and went through significant emotional and identity struggles. Eder emphasises that these medical practices were deeply shaped by cultural norms and anxieties about gender conformity, rather than purely medical necessity. Forced intersex surgeries remain prevalent in many parts of the world and are far from being merely a historical issue. In India, the illegalisation of such surgeries in infants is a recent development, with a landmark Madras High Court ruling in 2019 banning these non-consensual procedures. Eder’s book can be contextualised against this backdrop, raising the question: why did it take so long for such a legal and ethical shift to occur?
Eder in the final chapter discusses how gender transitioned from a clinical term used to manage intersex cases into a broader social and psychological concept used in queer and feminist discourse. Feminist scholars and activists found the idea that gender was learned rather than biologically determined to be a liberating notion. If gender roles were socially constructed, they could be deconstructed. This provided a theoretical basis for challenging traditional gender norms. The concept of gender role was expanded thereby differentiating between outward gender behaviours and an individual’s inner sense of self or “gender identity”. This distinction became crucial in understanding experiences of transgender individuals. These discourses foregrounded individuals’ experience of gender and recognised that it could differ from their assigned sex at birth. By questioning the idea of biological determinism, queer activists used the concept of gender to push back against heteronormative and binary understandings of sexuality and identity.
One could read scholars like Arpita Das [1], whose work extends Eder’s by exploring how gender assignment practices work for individuals with intersex traits in India. Like Eder’s examination of culturally embedded practices at Johns Hopkins, Das demonstrates that medical decisions in India are influenced by societal pressures and the cultural preference for sons. These studies emphasise that medical approaches to gender are not purely scientific but deeply influenced by the cultural, social and political context in which they are practised. By situating gender within its historical context, this book provides a framework for understanding the ongoing debates around gender, power, and identity.
Acknowledgment: Grammarly Pro was used for grammar checks and language editing during the preparation of this article.