Angela Moreno was told at 12 that she had to have her ovaries removed for health reasons, although her parents had been given the information about her true condition. Angela has Androgen Insensitivity Syndrome (AIS), a condition in which an XY fetus fails to respond to androgens in utero and is born with normal appearing external female genitalia. At puberty, the undescended testes began to produce testosterone, resulting in the enlargement of her clitoris. "It was never addressed to me that they were going to amputate my clitoris. I woke up in a haze of Demerol and felt the gauze, the dried blood. I just couldn't believe they would do this to me without telling me" (Batz, 1996).

Max Beck was carted to New York every year for medical treatment. "As I reached puberty, it was explained to me that I was a woman, but I was not yet finished... We'd head home again [after a treatment] and not talk about it for a year until we went again.... I knew this didn't happen to my friends" (Fraker, 1996, p.16). This lack of comprehension and explanation for the events happening to the child may result in their inability to make sense of their experiences and to encode them in a meaningful way. Parental and physician emphasis on the benefit of the medical procedures may also result in emotional dissonance which impedes the child's ability to process the experience; the child feels hurt, while being told that he or she is being helped.

Dissociation and Body Estrangement

Examining intersexed children's memories for their medical treatments may shed some light on the processes by which a child comes to understand traumatic events involving his/her body, and offers a unique opportunity to document what happens over time to the memory of these events. Because the child lacks the ability to comprehend the crossing of this body boundary as anything but destructive, regardless of the intents of parents and the medical community, genital procedures in childhood may have the same affective valence as CSA. As Leslie Young (1992) notes, the symptoms of sexual trauma are rooted in the issue of living comfortably (or not) in the body.

[T]he boundary between "inside me" and "outside me" is not simply physically crossed against a person's will and best interests but "disappeared" ... - not simply ignored but "made-never-to-have-existed." To physically challenge or compromise my boundaries threatens me, as a living organism, with annihilation; what is "outside me" has now, seemingly, entered me, occupied me, reshaped and redefined me, made me foreign to myself by conflating and confusing inside me with outside me. Of necessity this assault is experienced by me as hateful, malevolent, and entirely personal, regardless of the intentions of any human agents involved. (p. 91)

This confusion may be especially acute in intersexed children, whose bodies are quite literally reshaped and redefined through genital surgery and repeated medical treatments.

Among criteria listed as triggers for dissociative episodes during trauma, Kluft (1984) included "(a) the child fears for his or her own life... (c) the child's physical intactness and/or clarity of consciousness is breached or impaired, (d) the child is isolated with these fears, and (e) the child is systematically misinformed, or "brainwashed" about his or her situation." (cited in Goodwin, 1985, p. 160). Undoubtedly all of these factors come into play during the intersexed child's medical treatment; the child, having been told little or nothing regarding the rationale for the surgery and examinations, is fearful for his/her life, the child's genitals are surgically removed and/or altered, representing a clear breach of physical intactness, the child is isolated with fears and questions about what has happened to his or her body (and what will happen in the future), and the child is given information which does not reflect the true nature of the treatment or the details of the procedures.

Both Angela Moreno and Max Beck report extensive dissociative episodes. "I was a walking head for most of my adolescence" recalls Max (Fraker, 1996, p. 16). Moreno reports that "After years of therapy, she finally feels like she's in her body, filling out her skin and not just floating" (Batz, 1996). These statements are similar to those of CSA victims who report separating themselves emotionally from their bodies in order to withstand a physical violation. The woman subjected to repeated colposcopies reports that she "survived the vaginal examinations by completely dissociating herself from the lower half of her body -- that is, becoming "numb" below the waist, without sensations or feelings" (Shopper, 1995, p. 201). Freyd (1996) calls dissociation "a reasonable response to an unreasonable situation" (p. 88). Layton (1995) notes that fragmentation is a likely outcome of experiences such as these: "... if the mirror of the world does not reflect your smile back to you, but rather shatters at the sight of you, you, too, will shatter" (p. 121). Dissociative response appears to operate as a defense and consequence in both CSA and medical procedures.

Betrayal Trauma

Jennifer Freyd (1996) has proposed that forgetting of the experience is more likely to occur when the child relies on and must maintain a close relationship with the perpetrator. Betrayal trauma posits that there are seven factors predicting amnesia:
1. abuse by caregiver
2. explicit threats demanding silence 3. alternative realities in environment (abuse context different from nonabuse context)
4. isolation during abuse
5. young at age of abuse
6. alternative reality-defining statements by caregiver
7. lack of discussion of abuse. (Freyd, p. 140)
Certainly these factors operate in the medical management of intersexed children. Shopper (1995) suggests that medical procedures are "similar to those of child sexual abuse in the sense that within the family there is often a manifest denial of the child's traumatic reality. From the child's perspective, the family is seen as being in tacit collusion with the perpetrators (medical staff) of the traumatic procedures. This perception may lead to strong rage reactions against the parents, as well as affecting the sense of trust in the parents' ability to protect and buffer" (p. 203). Conversely, the child may stifle the recognition of this betrayal in order to keep the relationship with his or her parents intact. Freyd (1996) notes that "registration of external reality can be deeply affected by the need to preserve the love of others, especially if the others are parents or trusted caregivers" (p. 26). She also notes that the degree to which the child is dependent on the perpetrator, and the more power the caregiver has over the child, the more likely the trauma is to be a form of betrayal. "This betrayal by a trusted caregiver is the core factor in determining amnesia for a trauma" (p. 63).