“A male brain in a female body”: The question of psychological sex in a case of hermaphroditism presented by Valentin Magnan and Samuel Pozzi (1911)
- La Petite Sirène
- Jun 26
- 33 min read
Mathias Winter
Abstract
Objectives
This article explores the history of medical and psychological expertise on sex/gender identity by studying the presentation of a case of “hermaphroditism” given by the psychiatrist Valentin Magnan and the surgeon Samuel Pozzi in 1911. It examines how these authors dealt with the discrepancy between the organic and psychosocial dimensions of sex, and it highlights the epistemological and ontological problems that emerge. The article also discusses the continuing echoes in current controversies in gender medicine.
Methods
Our study consists of an in-depth analysis of a presentation given to the French Academy of Medicine regarding a case of “inversion du sens génital chez un pseudo-hermaphrodite féminin [sexual inversion in a female pseudo-hermaphrodite]”. We conducted a detailed analysis of the minutes of the presentation, with the aim of revealing the internal logic, theoretical presuppositions, and metaphysical implications of the clinical judgements made by Magnan and Pozzi. Our primary sources include other texts by Magnan and his contemporaries on homosexuality and “sexual perversion”. Historical and epistemological studies of sex, sexuality, and hermaphroditism are used as secondary sources. Our theoretical framework draws mainly on the epistemological concepts of Kuhn and Bachelard.
Results
The clinical observations presented by Magnan opposed the patient's organic sex, which was, despite the presence of ambiguous genitalia, unambiguously female given the histology of the patient's gonads (ovaries), and the patient's psychological sex, which was defined as male based on both the patient's sexual attraction to women and the patient's psychological and moral characteristics. The psychiatrist's discourse suggested both symmetry and ontological equivalence between these two dimensions of sex. Overlooking the potential role of early gender assignment, education, and social environment on the patient's self-identification as male, Magnan proposed a naturalistic interpretation of the case, summed up by the expression “a male brain in a female body”. In his earlier writings on “sexual inversion”, Magnan frequently uses the above phrase and the reciprocal “female brain in a male body”, directly echoing Ulrichs’ famous “female soul in a male body”. However, in the context of the 1911 presentation, the use of this phrase appears to reflect an epistemological impasse, which results from the conjunction of the paradigms “hermaphroditism” and “sexual perversion”. In contrast, Pozzi avoided this impasse by proposing a theory that highlights the role of the patient's social environment and beliefs in the development of their sexual instinct and the formation of their identity. This theory draws on the psychological mechanism of suggestion as well as on Darwin's reflections on the domestication of animals. This perspective introduces an ontological hierarchy between organic sex and psychological sex, the latter being likened, in some cases at least, to a kind of illusion.
Discussion
Our study contributes to the exploration of the historical distinction between sex and gender by revealing the gap between the views of Magnan and Pozzi and those of the pioneers of sexology and psychoanalysis. However, we have also highlighted some epistemological and ontological problems that still pervade contemporary gender medicine. In particular, these are to be found in the persistent opposition between essentialist and environmentalist approaches to gender identity, in debates around the place of medical diagnoses in gender reassignment, and in the controversies over the role of social contagion in adolescent gender dysphoria.
Conclusion
Medical and psychological expertise on gender remains embedded in an epistemological matrix inherited from the field of sexual medicine in the late nineteenth century. The resulting intrinsic limitations call for an in-depth reflection on the ontology of gender identity.
1. Introduction
This article explores the history of the medical definition of sex through the study of a presentation delivered in 1911 at the Academy of Medicine by the alienist Valentin Magnan and the surgeon Samuel Pozzi. An original example of collaboration between a psychiatrist and a surgeon, this discussion of a case of “inversion of the genital instinct in a female pseudo-hermaphrodite” sits at the crossroads of the history of “hermaphroditism” and the history of psychiatry. However, it has only been the subject of partial or allusive commentary in scholarly historiography. The aim here is to deepen the analysis in order to shed light on the genealogy of contemporary medical controversies about gender.
Magnan and Pozzi’s report primarily concerns the epistemological history of “hermaphroditism,” or what is now referred to as intersex conditions. It recounts the case of a 30-year-old individual, “Mr. X…”, in whom surgery for an abdominal tumor revealed internal female genital anatomy (ovaries and uterus). His surgeon, Samuel Pozzi (1846–1918), a pioneer of modern gynecology, founded the first university chair in France dedicated to this specialty. He was also one of the leading international experts on hermaphroditism and, as such, a major representative of the “gonadal era”—that is, the paradigm which, according to historian Alice Dreger, dominated the medical understanding of sex in the West from 1870 to 1915. This paradigm defined “true” sex exclusively based on the male or female nature of the gonads and, therefore, identified men strictly with testicles and women with ovaries. In this view, most cases of “hermaphroditism” were reclassified as cases of “pseudo-hermaphroditism,” labeled “male” or “female” depending on the individual’s gonads. Thus, the patient presented by Magnan and Pozzi was considered a “female pseudo-hermaphrodite”—in other words, a woman whose sex had been erroneously identified.
What sparked the doctors’ interest—and constitutes the central issue of a discussion that, in hindsight, seems rather strange—was precisely the fact that Mr. X… proved to be a man “from a psychic point of view.” Raised as a boy, he had early expressed sexual interest in girls and even married a woman. His sexual instinct, therefore, was oriented in the opposite direction of what would be expected “naturally” in someone with ovaries: from this perspective, he exhibited an “inversion of the genital instinct,” in other words, an “instinctive perversion”—a subject in which his psychiatrist was a recognized expert. As chief physician of the admissions department at Sainte-Anne Hospital, Valentin Magnan (1835–1916) was not only the well-known promoter of the concept of degeneration, but also the author of numerous works on “sexual perversions.” The article he co-authored in 1882 with Charcot had, in fact, introduced the notion of “inversion of the genital instinct” in France. Largely presented by Magnan, the case of Mr. X… thus belongs not only to the history of intersex conditions, but also to the history of homosexuality and “perversions,” and consequently to the history of psychiatry.
To today’s reader, Magnan and Pozzi’s report appears all the more curious because it reflects ideas that were already, in 1911, partly outdated or in the process of becoming so. On the one hand, within the framework of the medical understanding of hermaphroditism, the paradigm linking sex unambiguously to the gonads was beginning to be challenged in favor of a broader view that included overall anatomy, social identity, and the individual’s subjective relation to their sex. However, it would take until the 1920s and the progress of endocrinology—particularly the discovery of sex hormones—for a fundamental shift to occur in the understanding of sexual development physiology. On the other hand, the sexological work of Havelock Ellis and Magnus Hirschfeld, and of course the early psychoanalytic work of Freud, had already begun—by the end of the previous century—to transform perspectives on “sexual perversions” and more generally to expand the conceptual and clinical field of “psychosexuality.”
The epistemological paradigms that underlie Magnan and Pozzi’s presentation have been extensively studied in historiography dedicated to the genesis of modern categories of sex and sexuality, as well as in key works on the history of “hermaphroditism.” Furthermore, several sociological and philosophical studies have critically highlighted how medical conceptions are rooted in binary gender norms, especially regarding the issue of intersex conditions. This article, by contrast, aims to show how Magnan and Pozzi’s presentation reveals certain aporias that run through the history of the medical definition of sex from the 19th century to contemporary conceptions of “gender identity.” In particular, it seeks to demonstrate how the notion of “psychic sex” poses not only epistemological problems for medicine and psychiatry but also ontological ones—issues that concern both the mode of knowledge and the kind of reality to which this “psychic” sex refers.
To this end, we offer a micro-analysis of a presentation centered on a unique case, aiming to reconstruct the variations and internal logic of the clinical judgments in order to uncover their theoretical background and implicit metaphysical stakes. Referring in particular to classical concepts from Kuhn and Bachelard, we examine how the psychiatrist and the surgeon attempt to make sense of the anomaly represented, for them, by the case of Mr. X… Rather than approaching their discourse as a reflection of clear-cut positions, we aim to highlight the hesitations and uncertainties it reveals.
Our first section will detail the clinical observation presented by Magnan and show how it suggests an epistemic and ontological equivalence between “organic” and “psychic” sex. The second section will trace the genealogy of the phrase “a man’s brain in a woman’s body” used by the psychiatrist and explain the reasons for the epistemological dead-end he encountered. The third section will focus on the theory of “artificial inversion” proposed by Pozzi. Based on psychological mechanisms, this theory seems to imply an ontological asymmetry between organic sex and “psychic” sex. Our discussion will address the persistence of these aporias in contemporary medical controversies surrounding gender and “transidentity.”
2. “Organic” Sex and “Psychic” Sex: From Discursive Symmetry to Ontological Equivalence
In the presentation by Magnan and Pozzi, the clinical case itself is primarily developed by the psychiatrist. Magnan presents all the anatomical, behavioral, and psychological data of the patient, as well as the conclusions of the histological examination of the gonads. Pozzi, by contrast, incorporates the case of Mr. X… into a broader discussion of “pseudo-hermaphroditism,” and comments specifically only on the oncological aspects, since—as the full title of the presentation indicates—it is also a case of “successfully functioning ovarian sarcoma.” The patient was, in fact, known to the psychiatrist before being operated on by the surgeon, as Pozzi thanks Magnan for having entrusted him with this “fascinating subject” ([1], p. 239).
It is immediately apparent that Mr. X’s clinical history is not one of the incidental discovery of a previously unsuspected case of “pseudo-hermaphroditism.” The brief biographical details at the beginning of the report show that the issue of “ambiguous sex” [5] was present from birth: “sex determination gave rise to some hesitation, but the subject, a vulva-shaped hypospade with a fairly developed penis-like appendage, was considered male” ([1], p. 223). Magnan does not specify whether this assignment to the male sex had been medically assessed at the time, but it does not seem to have been challenged subsequently: the occurrence at puberty of periodic genital discharges “did not attract the family’s attention” and was attributed to “hemorrhoidal flow” ([1], p. 223). However, he notes that around the same time, the patient “experienced a brief bout of melancholic depression with suicidal thoughts; he was discreetly monitored, and a large knife was found in his room, with which he admitted he wanted to kill himself” ([1], p. 223). Magnan does not comment on this episode and interrupts the anamnesis here to proceed to the clinical description, which is structured in two parts.
The first part presents the stages of an examination that, proceeding from the outside toward the inside of the body, progressively reveals its femininity. This is already apparent in the description of the patient’s “external habitus”: a short individual (148 cm), Mr. X… has a “rounded neck without muscular protrusions,” a “barely prominent” larynx, a “rather feminine” voice, “fine and sparsely haired” skin, and “breasts” “the size of a large walnut” ([1], p. 223). Without specifying whether he conducted the examination himself, Magnan then meticulously describes the external genital apparatus, first indicating the dimensions of the “peniform appendage” “in a flaccid state,” then specifying that “in erection, this peniform appendage lengthens, thickens, and curves slightly downward, held by two clearly defined bands, remnants of the cylindroid portion of the corpus spongiosum” ([1], p. 224). The precise and technical medical vocabulary carefully downplays the masculine connotation of this organ, under which “two skin folds resembling labia majora delimit a vertical slit leading to a vestibule at the bottom of which the urinary meatus can be seen” ([1], pp. 224–225). The examination of the sex then becomes more invasive: the insertion of a “probe” into this orifice reveals a “small vaginal canal,” while the rectal examination reveals a “cylindroid body, similar to a large fountain pen measuring 12 centimeters in length,” which the informed audience would already recognize as the uterus. Finally, surgical dissection allows for a precise determination of the nature of the internal genital organs: “they are exclusively female—uterus, tubes, ovaries, without any trace of male organ” ([1], p. 225, emphasis added).
Yet the anatomical examination is not enough to formally establish the patient’s “true” sex. Pozzi emphasizes later that “the macroscopic characteristics of the left tumor, together with the presence of a uterus and fallopian tubes, would not have sufficed to determine a diagnosis of femininity”; neither the eye, nor the instruments, nor the dissection suffice to define sex “definitively” ([1], p. 242). Certainty in the medical judgment of sex can only be achieved through the pathologist’s microscope, which objectifies the histological nature of the gonads—in this case, ovaries. Magnan thus recalls the conclusions of the anatomopathological examination, accompanied in the text by four reproductions of microscopic slices of the ovaries, constituting the visual and definitive proof of femininity. From “external habitus” to gonadal tissue, the path followed by the medical gaze strips the body of its initial ambiguity, allowing for the following conclusion: “We are therefore, organically, clearly dealing with a woman” ([1], p. 227). This categorical judgment results from projecting the gonadal sexing onto the entire body. The “synecdochic relation between the organ and the person,” as historian Thomas Laqueur puts it ([15], p. 285), identifies the individual not by their genitals, but solely by their gonads: the ovaries revealed by the surgeon and the pathologist are sufficient to define a “female body,” regardless of its other observable characteristics. The “woman” is the female gonad [2].
Following a discursive trajectory partly symmetrical to that of the first part, the remainder of the report reviews all the traits used to establish the patient’s “psychic” sex, ultimately leading the psychiatrist to assign “a man’s brain” to the patient. This conclusion comes at the end of both a synchronic and diachronic investigation, based on the patient’s account but also, it seems, from his social circle—though it is not specified who was consulted.
Magnan first describes Mr. X’s sexual behavior during childhood:
“From a psychic point of view, the important fact is that this female pseudo-hermaphrodite displayed from early childhood the behavior, habits, character, desires, and instincts of a boy, of a man. He participated in the games and activities of his male peers, but felt more attracted to the company of girls; he was courteous toward them and tried, whenever possible, to arrange secluded encounters with one of them, during which, after exchanging caresses and mutual fondling, he attempted copulation” ([1], p. 227).
These details highlight the early and spontaneous nature of a sexual instinct contrary to what should have been, from Magnan and Pozzi’s perspective, the “natural” instinct of an ovary-bearing individual (cf. infra). This precocious instinct also carries etiological implications, as we will see in the third part. Effectively erasing the initial doubt surrounding sex, it also appears to biologically ground the perception of the individual by his peers, and hence his subsequent socialization: “He was regarded by all as a man, and when it became necessary, his engagement to be married seemed entirely natural” ([1], p. 227). Institutionalized by marriage, sexual difference finds its ideal arena. It is thus evident that, for Magnan, Mr. X… is all the more a man in that he is a good husband:
“The young couple was well united, the husband adored his wife, and she, fortunately, surrounded him with the deepest affection; she never tired of telling her family the joy and happiness she found in her home; and in private conversations with old friends, she hinted that their marital relations were entirely fulfilling” ([1], p. 227).
This shows how much importance the psychiatrist gives to the wife’s testimony, whose repeated expressions of marital satisfaction are not seen as suspect. The social and relational context in which sex is embedded here seems able to alter its ontological status: Mr. X… is no longer merely “seen by all as a man,” but, given that his wife attests to his male behavior, he is a man.
It is nonetheless necessary to push the exploration further by directly questioning the subject about his sexual physiology. Mr. X…, Magnan explains, “tells us that he has sexual relations several times a month, and occasionally twice in the same night, accompanied by intense pleasure and spasms.” Admittedly, “there does not appear to be ejaculation,” but “the erection ceases after the spasm as in the normal man” ([1], p. 227, emphasis added). In the intimacy of the night, Mr. X… not only satisfies his wife, but also experiences pleasure himself — like a “normal” man.
Beyond evaluating sexual behavior, Magnan’s report also highlights certain moral qualities that mark the transition from an almost animal masculinity to psychosocial virility. Referring to Mr. X’s attitude during his wife’s illness and subsequent death from tuberculosis fifteen months after their marriage, Magnan writes: “the illness only strengthened the affectionate bond uniting the couple and, on many occasions, revealed the husband’s firmness and energetic will” ([1], p. 227, emphasis added). After being absent for the surgical operation, Mr. X… “returned to his wife’s side and never left her bedside, attending to the smallest details of her treatment, fighting with great energy to conceal his despair” ([1], p. 228, emphasis added). Apparently eager to dispel any ambiguity about the emotional significance of such behavior, Magnan adds this narrative “to show clearly that he [Mr. X…] always remained, psychically, the husband” ([1], p. 228, emphasis added). His unwavering devotion to his wife, his firmness of character, his energetic attitude in the face of adversity, and his emotional self-control all show that the psychiatric assessment of his “psychic” sex refers here to moral qualities culturally coded as masculine.
The final — though not necessarily sufficient — criterion of this psychic masculinity is the patient’s conviction regarding his own sex, which is also characterized by a morally valued quality: constancy. “One cannot help but insist on the fact that Mr. X… never had the slightest hesitation about the nature of his sex” ([1], p. 228, emphasis added). It is surprising, however, that Magnan does not question the subjective function of this conviction, especially since he notes that Mr. X… responded with suicidal violence to the first physiological signs of his “organic” femininity. Nor does the psychiatrist seem concerned that his own investigation might introduce doubt into the patient’s mind. On the contrary, this subjective conviction derives clinical value from being shared — once again, socially validated: “To him, he is a man, and the same conviction is held by the wife; she has a husband, a real husband” ([1], p. 228). Rooted in social and relational fabric, “psychic” sex thus belongs to a network of institutions and shared beliefs in which the psychiatrist himself also participates. Everything happens as though Magnan, despite knowing the “true” sex of Mr. X…, cannot bring himself to consider him as anything other than a man: he consistently refers to him using masculine pronouns, while his surgical colleague explicitly refers to him as a woman.
The practical attitude recommended by the psychiatrist clearly reflects his own commitment to recognizing the social and intersubjective dimension of what would today be called the patient’s “gender”:
“In the special context of the young couple, the doctor’s role was clear: silence. He had no business raising a question that had never been asked and which, moreover, could only be addressed by the two people concerned — the husband and the wife. In any case, it would have been cruel and unnecessary to disturb an environment in which the accomplished facts were seen by all as a normal and legitimate situation” ([1], p. 229, emphasis added).
Here, Magnan adopts a position similar to that of other authorities on “hermaphroditism” of the time, who readily acknowledged that ethical or compassionate reasons might justify withholding disclosure of the “true” sex of those concerned [12]. In any case, Mr. X’s situation presents no medico-legal difficulty: no one disputes the legality of the marriage, especially now that the wife is deceased. Magnan is also aware that revealing “mistakes” in the sex of “pseudo-hermaphrodites” — and rectifying them socially and legally — can have devastating consequences such as suicide, as in the emblematic case of Herculine/Abel Barbin [22], [23]. But what matters here is that the psychiatrist recommends silence as self-evident and relegates the “question” of sex to the exclusive intimacy of the couple. In his concern not to disturb a “normal” situation, Magnan thereby relativizes — to some extent — the authority of medical knowledge over sex, placing priority on the social order and the patient’s subjective relationship to their sex [12].
Symmetrically to the determination of “organic” sex, “psychic” sex could therefore be subject to a psychiatric diagnosis, with the psychiatrist acting as something like an expert in masculinity. Yet while the medical judgment that establishes organic sex draws on specific knowledge and tools, the judgment regarding psychic sex relies only on the most conventional — if not outright stereotypical — criteria of “masculine” and “feminine.” In matters of “gender,” psychiatric judgment does not involve any particular technical expertise: it merely articulates what anyone could observe — that the patient is “seen by all as a man,” including by himself — and by the psychiatrist. At best confirmatory, or even purely tautological, medical expertise adds nothing to the socially recognized categories of “man” and “woman.” Yet Magnan does not acknowledge this inherent limitation, which perhaps irreparably links judgment about “psychic” sex to what we now call gender stereotypes. On the contrary, his discourse establishes a discursive symmetry between the two registers of expertise and seems thereby to introduce an ontological equivalence between organic sex and psychic sex. And yet this equivalence only sharpens the clinical paradox posed by the case of Mr. X…: while the anatomopathological examination has established that “organically, we are clearly dealing with a woman” ([1], p. 227), the psychiatrist’s examination shows with arguably equal certainty that “we” are dealing with a man — psychically.
In concluding his report, Magnan summarizes this paradox with a phrase that reveals his perplexity:
“Such an unshakeable psychic state, which never wavered for even a moment, is rare, and it seems justifiable to say that we are dealing here with a man’s brain in a woman’s body” ([1], p. 229, emphasis added).
The “brain” thus appears as the bearer of the ontological consistency that “psychic” sex has acquired over the course of the case presentation. Organic interpretation emerges as the only way to account for an “inversion of the genital instinct” which is soon described as “absolute” ([1], p. 230). We shall see that this results, for Magnan, from an attempt to overcome the epistemological obstacles arising from his normative conception of sex and sexual instinct.
3. The Sexed Brain: Genealogy of an Epistemological Deadlock
From the perspective of Magnan and Pozzi, the case of Mr. X… is exceptional in that it brings together two pathologies related to sex: on the one hand, “pseudo-hermaphroditism,” which involves the transgression of the anatomical norm governing the “formation” of the genital organs; on the other, the “inversion of the genital instinct,” which corresponds to a “deviation” or “perversion” of sexual instinct. It thus sits at the intersection of two paradigms or two “styles of reasoning,” one concerning sex and the other sexuality. The 1911 report specifically illustrates the complex intertwining of these two paradigms.
From the standpoint of the paradigm of “true” sex, the biologically normal—i.e., heterosexual—orientation of sexual instinct is defined by the nature of the gonads. This is a principle that “pseudo-hermaphroditism” can dramatically confirm. Magnan thus emphasizes that “the awakening of normal appetites and instincts” at puberty may reveal an individual’s “true sex” (p. 229). This is illustrated by several cases frequently cited in the medical literature from the 1880s onward, especially that of “Alexina,” better known today as Herculine Barbin since her rediscovery by Michel Foucault. As Magnan recalls, Alexina, raised for twenty years as a girl among other girls, “soon experienced manifestations that shed light on her appetites and instincts and which, at first, surprised even her” (p. 229). Similarly, “Ernestine G…,” a young widow, “openly took mistresses” and was found, like Alexina, to have testicles: “Ernestine G… was a man, and in seeking female relations, she was obeying a normal instinctual need” (p. 229). The “true” sex defined by the gonads is thus “normally” expressed through attraction to the opposite sex, regardless of the sex in which the individual was initially socially recognized. Such subjects are described by Pozzi as “heterosexed” or “orthosexed,” that is, “sexed in the normal direction” because they have “sexual instinct only for the sex truly different from their own and obey, like well-formed individuals, the congenital instinct of heterosexuality” (p. 234).
By contrast, Mr. X… falls under the category of “inversion” in that, while possessing ovaries, his sexual instinct is directed toward women. He therefore effectively falls within the clinical domain of homosexuality, allowing Magnan to draw this retrospectively disconcerting comparison:
“This inversion of the genital instinct, which we have found to be so absolute in our subject, sometimes appears with the same intensity in a man driven by an obsessive love for another man, seeking intimacy with him to the exclusion of the opposite sex.” (p. 230)
The rigid identification of an individual’s sex with their gonads places in the same clinical category individuals whose behavior and subjective experience differ considerably. While Mr. X… behaves like a heterosexual man and appears to flourish in ignorance of his “instinctual perversion,” the “normally conformed” homosexual patients to whom he is compared are painfully aware of their homosexuality. At the end of his presentation, Magnan revisits the case of a tormented professor previously mentioned in his article with Charcot; Pozzi, for his part, recounts the case of a military man who sought his help to “overcome a psychological state he found horrifying” (p. 232). Clinically questionable, the comparison between Mr. X… and these patients is also problematic in light of Magnan’s own logic, which should have led him to compare the case to other instances of female homosexuality. In some respects, this comparison only serves to reinforce Mr. X…’s inclusion within the masculine domain.
The problem of sexual inversion is primarily expressed through the formula “a man’s brain in a woman’s body.” In this way, the 1911 report fits fully within the lineage of Magnan’s earlier works. It directly responds to the theme of “a woman’s soul in a man’s body,” introduced in 1868 by German writer and jurist Karl Heinrich Ulrichs (1825–1895), in a bid to normalize homosexuality—a perspective widely taken up by emerging sexology. In their 1882 study, Charcot and Magnan explicitly mention Ulrichs but without referencing the brain. This study is cited by physician Eugène Gley in an 1884 article reviewing various works on “aberrations of sexual instinct.” Gley concludes that in cases of inversion, it is the central nervous system, not the genitals, that determines sexual function, so that “with respect to sexual instinct, the brain of these men is a woman’s brain, and that of these women, a man’s brain” (p. 92). The following year, Magnan adopts this formula, writing about inversion of the genital instinct:
“What dominates in all these cases is the obsessive idea of man for man, woman for woman; the origin is essentially cerebral; it is, in a way, the brain of a woman in a man’s body and the brain of a man in a woman’s body.” (p. 462, our emphasis)
The reference to the brain is introduced cautiously here, primarily pointing to the psychic dimension of sexual attraction and, clinically, to the issue of obsessive ideas. Magnan would continue to use this formulation, describing in 1887, for example:
“subjects who, with all the attributes and outward appearance of one sex, exhibit the feelings, aptitudes, appetites, and instincts of the other; a man’s brain, for example, serving a woman’s body and vice versa, producing this strange anomaly of the man exclusively in love with other men and indifferent to women, and reciprocally the woman showing an exclusive inclination toward women.” (p. 90, our emphasis)
It is somewhat surprising that the brain is described here as being “at the service” of the body, rather than the reverse. In any case, “the brain” stands, by metonymy, for not only ideas but also the full range of “feelings,” “aptitudes,” “appetites,” and “instincts” that constitute sexual identity from a psychological and behavioral perspective. Ascribed to the brain, this identity is conceived in naturalistic terms of masculinity and femininity, with no regard for the relational and social dimensions evident in the 1911 clinical observation.
In any case, defining the brain is not sufficient to produce a scientific theory of cerebral sexuation. Admittedly, Magnan tried to provide a more precise theorization of the central nervous system’s role in the development of perversions. Based on a sexual physiology modeled on the reflex, he classified inversion of the genital instinct within “anterior spinal-cerebral disorders,” in which “a psychic influence, as in the normal state, acts on the genitospinal center; but here the idea, the feeling, or the inclination is perverted” (p. 89). Such an approach merely displaces the problem and does not compensate for the lack of knowledge about the brain. The formulas used by Gley and Magnan were also taken up by authors such as Krafft-Ebing, Havelock Ellis, and Freud. In a 1900 text, Havelock Ellis was categorical:
“But this is not an explanation; it merely crystallizes a superficial impression into an epigram. We know the soul only through the body; and although we say that an individual seems to have a man’s body and a woman’s feelings, it is quite another thing to dogmatically assert that a woman’s soul or even a woman’s brain is expressed through a man’s body. That is simply incomprehensible.” (p. 490)
It is likely that Magnan was at least indirectly aware of these criticisms, although he seems never to have responded directly (according to Ellis, Gley later stated that his assertion should not be taken “literally”). The recurrence of the formula “a man’s brain in a woman’s body” in the 1911 report thus reflects Magnan’s difficulty in updating his conception of the issue—and perhaps also his reluctance to acknowledge the contributions of German or British authors. In any case, it indicates the persistence of the constitutionalist conception underpinning Magnan’s approach: whether normal or “perverted,” sexual instinct and, by extension, the “psychic sex,” are inscribed in the individual’s constitution. Following his early work, Magnan indeed viewed “inversion” as congenital or “native,” a term later used by Pozzi. Mr. X…’s early sexual awakening thus testifies to the fact that his “psychic” masculinity results from his instinctive/cerebral constitution. This constitutionalist perspective is closely linked to the paradigm of degeneration, which permeates all of Magnan’s work.
The notion of degeneration constitutes the exclusive etiological horizon for highly heterogeneous clinical pictures and justifies the association of “instinctual perversions” with genital malformations, seen as “stigmata” of “hereditary degeneration.” It plays an epistemological role in connecting disturbances of sexual instinct with mental illness. In their 1882 study, Charcot and Magnan emphasized that sexual perversions are themselves mental disorders, even when they affect subjects who appear psychically and physically normal. Conversely, in an 1887 study, Magnan described three cases of hypospadiac or pseudo-hermaphroditic patients admitted to Sainte-Anne for serious psychiatric conditions. Such cases revealed the convergence—or even the organic solidarity—between genital and cerebral aspects of degeneration.
Yet Mr. X…‘s case appears to resist this theoretical framework, a fact that may not have escaped Magnan. First, the vocabulary of degeneration is strikingly absent from Magnan’s report, even though traces of it can be found in Pozzi’s (p. 235). More importantly, there is a stark contrast between the presentation of Mr. X…’s case and the clinical descriptions in Magnan’s earlier texts, in which even the faintest psychic symptoms or remotest family history were used as evidence of degenerative instinct. On the contrary, Magnan merely notes that Mr. X…’s father is “strong, robust, and healthy,” his brother a “healthy military man,” and finally that his mother, “very nervous, had suffered violent grief during pregnancy” (p. 223). Even though this may allude to hereditary concerns, it is not commented on. More surprising still, the examination of the patient’s “psychopathic state,” dominated by questions of masculinity, gives little weight to psychopathological elements, even tending to minimize them. Magnan notes that Mr. X… had pronounced suicidal tendencies in adolescence and suggests he remains fragile: during his wife’s illness, he “repeatedly” stated he could not survive her, and only her hopeful words “certainly saved him from suicide” (p. 228). Yet, rather than viewing these as signs of underlying mental pathology, the psychiatrist stresses the patient’s psychological normality. This “normality,” whose sexual, moral, and social dimensions were discussed earlier, also serves to objectify Mr. X…’s psychic masculinity, through a logic of mutual reinforcement: Mr. X… seems mentally sound primarily because he behaves like a “normal” man—i.e., a heterosexual man.
In sum, Mr. X…’s case represents an anomaly from the standpoint of both fundamental paradigms of Magnan’s approach—paradigms whose convergence ultimately confronts him with an epistemological deadlock. The problem is not merely that the strictly gonadal definition of “true” sex leads to a diagnosis of “inversion” in an individual who, phenomenologically and clinically, is a heterosexual man. It is also that attributing to him a “man’s brain” contradicts the very diagnosis of “inversion,” since it implies the normal, non-“perverted” nature of his sexual orientation.
The formula “a man’s brain in a woman’s body” thus ultimately only serves to describe a clinical situation that is difficult for Magnan to conceptualize: far from expressing a genuine theory of cerebral sexuation, it rather reveals the absence of a specific theory of psychosexuality. Nonetheless, the formula does, to some extent, express a metaphysical position that grants the “psychic sex” an ontological consistency comparable to that of organic sex: to speak of the brain seems to allow the psychiatrist to account for the fact that Mr. X… really is the man standing before him. This position contrasts sharply with that of his surgeon colleague.
4. Psychic Sex as Illusion
Pozzi’s account differs from Magnan’s in several key respects. First, the specific clinical aspects of Mr. X…’s case occupy a fairly secondary place. Since most of the somatic and psychological data had already been presented by the psychiatrist, Pozzi focuses only on the surgical and oncological aspects, which he discusses at length in light of the existing literature on ovarian tumors. More significantly, the surgeon devotes a large part of his presentation to broader theoretical considerations about the various types of “pseudo-hermaphroditism,” for which he proposes a “classification attempt” (p. 259). Mr. X…’s case is thus integrated into a much larger series of cases, its only particularity being the relative rarity of “female pseudo-hermaphroditism,” which Pozzi also calls “gyn-androidy,” in contrast to its male counterpart, “andro-gynoidy.”
A second divergence, mentioned earlier, concerns how the patient’s sexual identity is designated and conceived. By referring to this individual—whose “organic” femininity he is aware of—exclusively in the masculine, Magnan acknowledges the clinically irreducible nature of “psychic sex.” Pozzi, on the other hand, uses the feminine to refer to a patient he unambiguously considers to be a woman. For him, the “diagnosis of femininity” is confirmed with certainty through histological analysis of the gonads, while the patient’s genital formation falls within the category of “female hypospadias” (p. 257).
Unlike Magnan, Pozzi offers an explanation for the “inversion of the genital instinct” that opens the door to a psychogenetic conception of the formation of “psychic sex.” In the first part of his presentation, the surgeon devotes a lengthy discussion to the issue of the sexuality of “pseudo-hermaphrodites,” for which he proposes a three-part typology. The first category is that of the “asexual” or “oligosexual” individuals (p. 234), i.e., those whose sexual instinct is “atrophied.” According to the theory of the “genital reflex” underlying Pozzi’s discourse, sexual instinct is directly determined by the gonads. Consequently, when the gonads are atrophied or “reduced to a minimum,” as is the case in “most” pseudo-hermaphrodites, they only produce “very weak genital reflex actions” (p. 234).
Second, “heterosexed” or “orthosexed” patients are those whose genital instinct operates “in the normal direction”: in Pozzi’s view, this confirms the principle of a natural link between the gonads and heterosexual instinct. Finally, some individuals—such as Mr. X…—can be described as “homosexed” or “inverted,” since their genital instinct leads them to seek relationships with individuals of the same sex (in the gonadal sense). Compared to the previous two categories, this last one stands out in that it cannot be explained by any obvious physiological mechanism and therefore presents a theoretical problem.
To address this issue, Pozzi proposes distinguishing among “inverts” those who are “original and by birth,” and those who are “artificially” inverted (p. 234). “Primitive” or “native” inversion stems from a congenital malformation of the instinct; it may be described, using a phrase Pozzi borrows from Magnus Hirschfeld, as a “psychic hermaphroditism” (p. 233, italics in the original). Although observable in “some hermaphrodites,” this type of inversion also affects—if not more so—individuals who are “normally formed” (p. 238). Homosexual patients such as the professor mentioned by Magnan, or the tormented officer whose case Pozzi discusses, clearly fall into this category. The surgeon emphasizes that this “instinctive deviation” imposes itself on the subject, who is “truly not responsible for it, no more than a hypospade is for his deformity” (p. 233): from a moral standpoint, it is crucial to distinguish between the perversion of instinct and the perversion of “morality.” Etiologically, however, “native” inversion remains tied to the idea of degeneration, even if, as Pozzi notes, other “stigmata” are not always observable; it is, in any case, rooted in the individual’s constitution, and thus a form of natural causality.
There is, however, a second type of inversion—this time of “artificial” origin—which concerns patients with genital malformations, especially when such malformations lead to an initial error in sex recognition. In these cases, “inversion often appears to be produced by environmental influence, by education, surroundings, or suggestion” (p. 235). Pozzi uses the generic example of male pseudo-hermaphroditism, which is the most common:
“One can easily understand how an individual whom everyone considers a woman may come to believe it themselves, and—through imitation and autosuggestion, as much as through external suggestion—adopt the tastes and habits of a sex which is, in reality, not their own, since that individual has testicles. If they marry, they will therefore marry a man.” (pp. 235–236, emphasis added)
The principal mechanism involved in the psychogenesis of inversion—suggestion—directly recalls the work of Hippolyte Bernheim and the Nancy School. Pozzi is clearly familiar with it, explicitly naming “Professor Bernheim,” to whom, he says, he referred a patient who sought help to treat “overwhelming homosexual inclinations” through “hypnotism” (p. 233). It’s worth noting that the controversy between the Nancy School and Charcot’s Salpêtrière School involved not only hysteria but also the etiology of homosexuality and “sexual perversions.” This controversy thus serves as the background to the discussion of an acquired etiology of inversion, although Pozzi restricts it to specific cases of individuals raised in a gender different from their gonadal sex.
The theory of “artificial” inversion is also grounded in an environmental theory of the development of sexual instinct, which Pozzi explicitly ties to Darwinian thinking. Early in his medical training, Pozzi was a student of Broca, and at Broca’s request, he translated Darwin’s The Expression of the Emotions in Man and Animals. In the 1911 report, Pozzi insists that “we cannot stress enough the considerable influence that external circumstances can have on mentality, tastes, and instincts in both humans and animals” (p. 237), and explicitly cites some of Darwin’s experiments to support the claim that “perversion” can result from a “sexual education” governed by the same principles as animal “training” (p. 237, original emphasis). Instinct, then, could be subject to domestication, using the term that appears in the title of Darwin’s book cited by Pozzi. This proto-behaviorist theory does not completely oppose the theory of degeneration, since environmental influences do not rule out the possibility that some instinctual anomalies may serve as organic predispositions. But such predispositions would result more in a weakening of the instinct than in true perversion. In any case, in pseudo-hermaphroditism with sex misassignment, environmental influence seems all the more powerful because the body itself appears to conspire with “external influences” to foster the development of a psychic sex contrary to the gonads: the inversion of the genital instinct is “greatly encouraged by the presence of secondary characteristics which obscure the true sex in many of these subjects” (p. 236). Inversion, therefore, may be entirely artificial and acquired: “in such cases, it is quite possible that the normal genital instinct existed at the start, but it was, so to speak, smothered by external influences” (pp. 236–237). Through their suggestive effects, the social environment and the body itself thus contribute to a distortion of instinct.
This type of explanation clearly applies to Mr. X…’s case, although Pozzi is not entirely explicit on this point: in this “remarkable” case, inversion may indeed be “native,” but the “patient” is also described as having been “doomed by her malformation to homosexuality” (p. 232). Given the collegial tone adopted by both presenters, it is possible that the surgeon preferred not to openly criticize his colleague, or perhaps he was simply unaware of their divergences. In any case, Pozzi is clearly aware of the issue involved in labeling someone like Mr. X… as homosexual. He critiques authors such as Gley—whose views align with those of Magnan—for wrongly linking hermaphroditism and homosexuality “if by that word one means not so much the act itself as the desire to perform it” (p. 238). Or, as Pozzi continues, “from a physiological and psychological point of view, it is this latter aspect alone that matters” (p. 238). That some pseudo-hermaphrodites may engage in “homosexual acts” does not make them homosexuals, as long as their instinct is directed toward individuals of the opposite sex, relative to the sex they believe themselves to be.
By proposing an explanation of “acquired” inversion that makes it conceivable even in a “normal” subject (p. 232), Pozzi appears capable of avoiding the epistemological dead ends that confronted Magnan. In hindsight, it is also evident that his theory allows for the construction of psychic sex to be linked to objectifiable relational and social factors, rather than being treated as a hypothetical emanation of the “brain.” The epistemological gain here is doubled by a clinical benefit, insofar as this perspective enables the development of sexual identity to be embedded in the subject’s personal history and socialization.
But Pozzi’s position also carries important implications regarding the ontology of “psychic sex.” While the identification of psychic sex with the “brain” might have seemed to grant it a form of ontological consistency—albeit purely verbal—the theory of “artificial” inversion, on the contrary, rests on a clear hierarchy: the gonads are the only truth of sex, while sex as it is lived and socially recognized belongs to the realm of belief, if not illusion. Deeply contrived, this lived sex belongs to a psychological, social, and discursive order capable of veiling the organic sex with a misleading surface. Nevertheless, the distortion of instinct that results from it is, according to Pozzi, at the origin of a “perversion more real than apparent” (p. 238). Psychic sex thus inhabits an ambiguous ontology: it undoubtedly pertains to a reality distinct from that of organic sex, but it cannot be considered a mere illusion either.
5. Contemporary Extensions
According to historian Arnold Davidson, “any effort to write a unified history from hermaphroditism to homosexuality would amount to merging two figures that a proper historical epistemology must keep separate. The hermaphrodite and the homosexual are as different as genital organs and the psyche” (p. 88). Indeed, the presentation by Magnan and Pozzi highlights the paradoxes that can result from the conjunction of these two figures. However, it also shows that hermaphroditism was not only a “historically critical case” for the paradigm of gonadal sex, but that the distinction between organic sex and “psychic” sex could serve as a local theoretical solution compatible with that paradigm, prior to the formalization and generalization of the concept of gender role. Moreover, this text opens avenues for exploring the specificities of the French approach to the problem, which could provide a fresh perspective on the “ambiguous” reception of the concept of gender in France.
It should nevertheless be noted that Magnan and Pozzi’s presentation appears to have left little trace. It is unclear whether it sparked debate at the time it was delivered, but it is rarely cited in major subsequent works on hermaphroditism, such as the surgeon Louis Ombrédanne’s 1939 publication, or the important 1970 dissertation by child psychiatrist Léon Kreisler. In the English-speaking scientific field, it is evident that John Money—who was probably unaware of the presentation—makes no mention of it in his early work, despite having focused on individuals with congenital adrenal hyperplasia, who were biologically female but raised as boys—cases closely resembling that of Mr. X…
Beyond its interest for the history of epistemology, the presentation by Magnan and Pozzi reveals aporias that remain relevant in today’s medical debates on sex and gender. One key issue is the irreducible gap between medical expertise on biological sex and expertise on gender—understood as sexual identity in its psychological and social dimensions. In somatic medicine, the definition of sex has grown more complex over the past century, driven by advances in endocrinology, genetics, and more recently, molecular biology. Yet from gonadal histology to genome sequencing, there remains a divide between the technical conception of sex—based on knowledge and instruments inaccessible to laypersons—and the ordinary categories of gender, whether or not they conform to a strictly binary model of “male” and “female.” Recognizing this divide does not, of course, imply abandoning critique of the persistence of gender stereotypes and sexual binarism in biology and medicine. However, it does compel us to acknowledge the inherent limits of medico-psychological expertise on gender. As we saw in the case of Magnan, psychiatric judgment concerning “psychic” sex lacks any epistemic benchmark comparable to the biomarkers of somatic medicine and instead relies on socially shared representations of “masculine” and “feminine.” Certainly less stereotypical today than in 1911, these representations—which blend somatic, behavioral, and psychological aspects—belong to the backdrop of ordinary gender identification at a given time and place. Yet, it seems difficult to construct an expert perspective on gender that does not ultimately rest on such shared representations. As early as 1933, Freud noted that “masculinity or femininity is an unknown characteristic that anatomy cannot capture,” and, more crucially, that psychology “can provide no new content to the notions of masculine and feminine” beyond their ordinary meaning. Similarly, contemporary definitions of “gender dysphoria” in the DSM-5 or “gender incongruence” in the ICD-11—as well as the psychometric scales associated with them—can do little more than record the gender in which an individual identifies, is recognized, or seeks recognition. Indeed, the current emphasis on the exclusively subjective nature of gender identity only reinforces the impossibility of constructing a specific psychiatric definition. This is why the observation that “gender norms are passively and uncritically integrated by psychiatry” applies as much to contemporary psychiatry as to that of the 19th century.
Yet the “style of reasoning” inherited from late 19th-century psychiatry and sexology—which, according to Davidson, persists in some ways in the DSM—continues to support the idea that gender, conceived primarily in psychological terms, constitutes a legitimate object of medical expertise. While some specialists now question the evolving norms of clinical judgment in the field of gender, the issue of diagnosis remains central to political struggles around the “depathologization” of trans issues. In an article titled “Undiagnosing Gender,” philosopher Judith Butler addressed the practical and ethical problems tied to the diagnosis of gender dysphoria and exposed the paradoxes inherent in the DSM-IV’s definition of gender. More recently, the French organization Trans Santé France states on its website that gender is “a sociocultural and not a medical matter” and “not relevant to any diagnosis.” Consequently, the goal of “depathologizing trans identity,” championed by this organization, not only entails removing “gender incongruence” from the realm of pathology but also challenges the epistemic legitimacy of any medical judgment on gender. That medicine has nothing specific to say about a person’s gender identity aligns with recent legal changes in France regarding civil status sex changes. Such developments are not solely the result of successful political advocacy but also rest on epistemological preconditions—namely, the impossibility of a specifically medical definition of gender.
A second issue for which Magnan and Pozzi’s discussion remains relevant concerns the biological or socially acquired origins of gender identity. This question runs throughout the epistemological history of gender and is essential to its medico-psychological conceptualization. In a famous 1956 article, John Money and his collaborators sought to address the “venerable controversy over the hereditary versus environmental determinants of sexuality in its psychological sense.” Observing that gender role most often develops in line with the sex in which a child is raised—regardless of their gonadal or chromosomal sex—the authors proposed an explanation that in some ways echoes Pozzi’s. They attributed the development of gender to a process of “decoding and interpreting a plurality of signals,” not only social and environmental but also emanating from the body itself, in the form of primary and secondary sexual characteristics. This type of theory has been revived more recently in the psychoanalytic work of Jean Laplanche. But although approaches emphasizing environmental, social, and psychological influences have largely dominated the second half of the 20th century, the search for the biological foundations of gender identity has never ceased. The “essentialist” hypothesis that gender is determined by the brain has even regained traction since the 1990s, partly in response to critiques of Money’s work and in the context of intersex studies. Today, the elucidation of the neurobiological and genetic determinants of gender identity remains an explicit scientific goal, prompting critical studies in the wake of research on the “sexed brain.” That said, current medical literature tends to highlight “integrative” and “multifactorial” approaches. The DSM-5 also states: “Unlike certain social constructivist theories, biological factors are now considered to contribute—interacting with various social and psychological factors—to the development of gender” (p. 535).
However, it is doubtful that such statements suffice to resolve a problem whose ontological stakes were already evident in the presentation by Magnan and Pozzi. Thus, projecting “psychic” sex onto the “brain” not only essentializes and naturalizes gender but also lends it an apparently intangible reality, even if, as Havelock Ellis noted, it may be criticized for being superficial and “incomprehensible.” Conversely, emphasizing—as Pozzi did—the role of “external influences” in the development of a “psychic” sex opposed to organic sex risks treating gender identity as a potential illusion or false belief. While this problem clearly warrants deeper analysis, we can detect its presence in contemporary controversies around adolescent gender dysphoria. In a much-discussed 2018 article, physician and researcher Lisa Littman hypothesized that the recent rise in such cases might reflect a form of social contagion. Trained in gynecology, Littman unwittingly became an intellectual heir to Pozzi: by highlighting the influence of social media on the development of transgender identification in adolescents, she revived a modern version of the “suggestion” theory dear to the French surgeon. The point here is not to assess the validity of her hypothesis, but rather to note that it highlights the contemporary relevance of a metaphysical issue: the controversy sparked by her article stemmed in part from the perception that Littman’s hypothesis called into question the reality of the gender claimed by affected adolescents—contrary to the essentialist perspective that underlies most “trans-affirmative” approaches. The trans question thus continues to demand both metaphysical and moral reflection on the status of personal identity and psychic reality.
6. Conclusion
However distant it may seem from our current conceptions of sex and sexuality, the presentation by Magnan and Pozzi ultimately belongs to an epistemological framework that contemporary medicine may not have entirely left behind. Indeed, this framework underpins the very possibility of clinical judgments regarding “psychic” sex, while irreversibly binding them to the social and anthropological categories of gender—whether traditional categories such as man and woman, or newer ones such as “non-binarity.” It is therefore not surprising that medico-psychological expertise on “gender identity” is today being radically challenged. The future of such expertise—if it has one at all—will likely depend on an equally radical redefinition of its object.
Keywords
Sex
Gender
Intersex
Hermaphroditism
Sexual perversions
Valentin Magnan
Samuel Pozzi
History of medicine
History of psychiatry
Epistemology
Comentarios