The chapter begins by probing skeptical criticism, with key contributors like Stegenga (2018) questioning our unwavering trust in contemporary medicine. Next, it delves into the criticism of overmedicalization (see Moynihan and Cassels 2005; Conrad 2007; Le Fanu 2012; Parens 2013), viewed as an inappropriate use of medical resources for sociopolitical issues. The chapter also investigates the criticism of objectification related to the quality of care, drawing from thinkers like Cassell (2004), Haque and Waytz (2012), and Topol (2019). Rounding out the chapter, utilizing insights from Popper (2000) and Haslanger (2018), it identifies these criticisms as both social and internal to the practice of medicine. It concludes that medicine is falling short of its own standards, thereby posing fundamental questions about its nature and purpose to be explored in the succeeding chapters.

The chapter revisits the criticisms and challenges presented at the book’s outset. It highlights how the book’s central theses - the Systematicity, Understanding, and Autonomy Theses - help resolve issues related to skepticism, overmedicalization, and objectification in medicine. The chapter argues that a moderate position, supported by these theses, provides better understanding of these challenges and suggests potential solutions. The criticisms of skepticism are countered by increased systematicity in knowledge-seeking. Concerns of overmedicalization are tackled through the Autonomy Thesis, which argues that medicalization is justifiable if a condition is harmful and adequately understood by medicine. Objectification, as examined through the Autonomy Thesis, can impede medicine’s aim by undermining personal understanding. The chapter emphasizes the necessity of counteracting the potential decrease in personal understanding caused by standardization and technological advances.

The chapter argues that Robert Lowell erred morally, and thereby aesthetically – since art must be held to account – in his literary experiment of appropriating the epistolary voice of Elizabeth Hardwick, the esteemed literary critic, novelist, and co-founder of and regular contributor to the New York Review of Books, into The Dolphin (1973). Hardwick was Lowell’s second wife, then ex-wife at the time Lowell composed his sequence. Saltmarsh argues for a need to see her as a subject, and not an objectified "Lizzie" character. In quoting from many of Hardwick’s essays, letters, and writings, she hopes to restory what we think we know about the literary history of Lowell and Hardwick. Broadly, this chapter offers a reappraisal of both Lowell and Hardwick, and sheds light on the limits of confessional poetry, particularly when a writer is purporting to speak as an intimate other.

4. The aim of this chapter is to reflect on some crucial differences between the first and second editions of Psychoanalysis. Moscovici wrote the first edition during his ‘age of intellectual innocence’ when he knew only a little of Durkheim’s work; even the term ‘social representation’ came from Father Lenoble. He created his theory independently of Durkheim’s collective representations. None of the main concepts of Moscovici’s social representations were derived from Durkheim; instead, his main ideas contradicted Durkheim’s collective representations.

While in the two introductory pieces Moscovici expresses himself in Durkheimian fashion, the rest of the second edition follows the same path as the first. The major concepts of the theory, that is, objectification, anchoring, cognitive polyphasia, natural thinking, and communication, are discussed, although some of their meanings are changed or reformulated. Moscovici’s revision of the second edition has had major effects on the interpretation of his theory in several directions. It was the second edition that was translated into other languages and, therefore, it was interpreted in a Durkheimian way even though the concepts held by Durkheim and Moscovici were totally different. The root of the theory of social representations and communication between the two editions of Psychoanalysis remains puzzling.

Chapter 6 summarizes the changes to medical care in recent years. There is now a greater recognition that the projected social and psychological challenges of genital variations cannot be fixed by surgery. The first international consensus statement on intersex was published in 2006. The statement makes a number of recommendations to improve care. Controversially however, a new term disorders of sex development (and, later, differences in sex development, or DSD) was introduced to replace intersex and hermaphroditism. Biotechnological developments have been advancing rapidly. More has been learned about “normal” and “abnormal” sex development. However, parents still struggle to talk to children about their bodily variations, young people still worry about getting into relationships, childhood genital surgery is still considered the only way out of stigmatization, psychological expertise is still a low priority in specialist services and the huge potential of peer support is not fully realized.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

In a gendered world, doctors and caretakers took for granted that making atypical bodies more typical was a humane way out of a difficult situation for child and family. Had the professionals carried out proper research, they would have learned from their young patients that the approach was physically and psychologically risky. But research on the long-term effects was not carried out, certainly not from the patients’ perspective. There was also no comparison group made up of people growing up with unaltered genital variations. Research with adults is the topic of Chapter 4 of this book. Since the 1990s, a number of outcome studies with adults have identified many problems of childhood surgery, such as multiple operations, scarring, shrinkage, sensitivity loss, unusual genital appearance and sexual difficulties.

Chapter 8 begins by pointing out the current lack of collective clarity about the role of psychological care providers (PCPs) and suggests that researchers and practitioners make collective effort to develop the role of PCPs in sex development in future. Meanwhile it outlines the psychological consultation process that is generic and familiar to most PCPs. The author provides an initial assessment template and summarizes the popular psychotherapeutic interventions. The template is visible in several of the practice vignettes in the ensuing chapters of the book. The author ends the chapter by arguing that the tertiary environment is set up for diagnostic workup and treatment and unsuitable for the kind of ongoing psychosocial input that is needed by individuals and families living in their communities. The author makes a case for PCPs in DSD centers to collaborate with peer support workers to enable nonspecialist providers in the community to contribute to ongoing support for individuals and families.

Chapter 2 begins with a brief summary of typical embryonic development of the urogenital and reproductive systems. Where the sex chromosomes, reproductive organs and the genitalia in combination do not fit the social categories of female and male, doctors and scientists used to call these physical outcomes hermaphroditism and intersex. They debated for a long time on the “true sex” of the individuals but could not agree on which of the biological sex characteristics should count as their true sex – should it be the sex chromosomes, the gonads or the genitals? Although in the age of genetics, much more is known about how the atypical features have developed. At the same time, people who are impacted by the variations are increasingly disputing medical framing of their differences. The twenty-first century was to seed a new and ongoing debate between the new medical term, differences in sex development (DSD) and intersex, which is now reclaimed by many impacted adults.

Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Not all sex variations are apparent at birth. Sometimes they are internal and therefore not visible, that is, children are born looking like a typical boy or girl. The child may be brought to medical attention much later, for example when puberty does not follow the expected path. Many of these care users were not told the truth about their biological variation because adults believed that the information would harm them. At the same time, the care users also noticed that they were fascinating to health professionals, who may examine them in droves. Some of them did not discover the truth about their diagnosis and the treatment until mid-life.

For children whose external genitalia look different, when surgical safety and techniques improved, it became routine to align the urogenital anatomy of newborns and young children to the assigned gender. The gender-genitalia alignment was believed to be important psychologically for child and family. Because surgeons found it easier to feminize than masculinize the genitalia, most babies with genital variations were assigned female. From the 1990s, some of these adults have spoken out, talking of too many operations, been too often examined by too many and not understanding what was happening.

Chapter 9 tackles the theme of choosing “normalizing” interventions, which applies to children and adults with variations. It explores the limits of choice regarding invasive and irrevocable “normalizing” interventions in the field of sex development. It considers the role of emotion in decision-making and the complexities of obtaining informed consent. In the practice vignette, demand for surgery by a young person (with CAH) is a foregone conclusion – a familiar scenario in DSD services and one that places the psychological care provider (PCP) in an ambiguous position. The service user also has clear psychosocial care needs. She brings a unique suite of intersecting social circumstances that place demand on the PCP to be fluid and responsive to the dynamic and challenging referral context. The PCP in the vignette does not have the answers, but it is hoped that the story opens up conversations on the theme.

Psychological care is endorsed in DSD medicine. Psychosocial research has been on the increase. But these positive moves have not given psychological practice the kind of collective focus that is enjoyed by the biomedical disciplines. However, psychological care providers have a wide variety of thinking tools and practice techniques to draw on, if to work in an ad hoc way at times. These tools and techniques do not change, but some are more useful and relevant than others for this service context. In Chapter 7, the author discusses the strengths and weaknesses of key theoretical frameworks in healthcare psychology. A major weakness of the individualistic models is their lack of capacity to address structural inequalities in psychological wellness and distress. The author introduces aspects of the Power Threat Meaning Framework and describes how to draw from its theoretical richness to think systemically about what sex variations pose to individuals and families in the social context and how they are responded to. The Framework provides the theoretical backbone for some of the practice vignettes in the final section of the book (Chapters 9–14).

In the 1990s, some former patients mounted street protests in front of medical conferences to draw attention to their trauma. They reclaimed intersex as a personal identity and campaigned for healthcare reform. These developments are the focus of Chapter 5. Intersex is coming out of the closet more and more, through being a topic in television documentaries, novels, films and art. Intersex activists challenge medical authority to change practice. Furthermore, they are not waiting for doctors and scientists to come to their viewpoints. They have successfully lobbied human rights agencies to position childhood genital surgery as a violation of their human rights. They demand that surgery is delayed until the child can give informed consent or is at least old enough to participate in the discussion and offer their agreement.

In Chapter 10, the author suggests immense possibilities for psychological care providers (PCPs) to contribute to compassionate care following the birth of a child with variations (and in the antenatal period). Psychosocial research and first-person accounts inform us of caretakers’ brokenness, which is often responded to by “normalizing” the child. Here, the author suggests that PCPs work with caretakers in a grief-informed way. Grief is a language that everyone understands and compels services to privilege psychological safety as a first care principle. The practice vignette is built around an expectant mother in difficult circumstances with an unborn child with TS. However, the concept of grief is also relevant for older children and adolescents who are newly diagnosed. Indeed processing loss is integral to adjustment, whereby taken-for-granted ideas of selfhood give way to new identities.

This chapter examines the peculiar practice, common in late antique epic poetry, of comparing a character to a divinity stripped of their visual attributes. From the works of Claudian, Nonnus, and Colluthus it analyzes three case studies that epitomize this form of comparison and illustrate its use in a specific literary and cultural context. Such comparisons are shown to rely on the reader’s familiarity with visual representations of the pagan gods and to reflect a growing interest in and engagement with the visual arts in late antique literature. In defining characters by attributes they do not possess, the poets draw attention to their visual ambiguity and vulnerability, and allow internal and external audiences to gaze at them uninhibitedly. Female characters in particular are thus proffered as objects of the lusting gaze and are denied individual visual identities and narrative agency. This literary emphasis on artistic beauty, stripped of its attributes and, by extension, divine power, resembles contemporary Christian attempts to de-contextualize pagan artworks by removing their religious attributes and associations, reframing them as purely aesthetic objects.