“The Ultimate Woman Is a Man”: An Analysis of Medical Authority and the (In)Visibility of Intersexuality in House, M.D.

Abstract: The medical drama House, M.D. has been the subject of numerous publications and has even been used to teach medicine to university students. This paper asserts that the discourses of medical authenticity that surround House, M.D. impart an aura of medical authority to the show that is further enhanced by its performative enactment of medical professionalism. As a result of this, the series is shown to be emboldened with the discursive power of modern biomedicine. Accordingly, this paper argues that the depiction of intersex people as a socially marginalized and medically stigmatized group gains special significance, as the show has the power to either reaffirm or challenge their marginalized status, and, along with that, the underlying heteronormative gender system. Hence, this paper utilizes the concept of heteronormativity in conjunction with Judith Butler’s conception of gender performativity and Michel Foucault’s theory of the medical gaze to analyze the portrayal of intersexuality in the episode “Skin Deep.” The paper demonstrates that rather than unfolding the deconstructive potential of intersexuality, the show reinforces heteronormative standards as it represents intersexuality as a pathological aberration.

The immensely popular medical drama House, M.D. has not only attracted considerable critical attention during the course of its eight-year run from 2004 to 2012 but has also been the subject of numerous publications regarding its medical accuracy. Interestingly, it has even been used to teach medicine to university students (“Neues”). The show depicts the “eccentric medical genius” Dr. Gregory House and his team of specialists at “the fictional Princeton-Plainsboro Teaching Hospital in New Jersey” (Włudzik 231)1 as they are tasked with solving cases “that have baffled other doctors” before them (Burger 355).

In the 2006 episode “Skin Deep,” which aired during the show’s second season, House’s team is tasked with resolving the mystery surrounding the inexplicable violent outburst and subsequent collapse of the female supermodel Alex during a fashion show. After a series of incorrect diagnoses by House’s team, House ultimately discovers that she is intersex2 and suffering from the effects of cancer on her testes (“Skin Deep”). This particular portrayal of intersexuality was met with harsh criticism by members of the Intersex Society of North America (ISNA), with April Herndon—one of its representatives—remarking in an article on the organization’s website that she was “shocked and horrified” by the show’s treatment of intersexuality, describing it as “one of the most offensive and hurtful portrayals of people with intersex conditions that I’ve ever seen.”

This raises the question of how intersexuality was portrayed in the episode, what made this representation so problematic, and why a portrayal of a supposed medical disorder on a popular TV show should be relevant. My article aims to answer precisely these questions. In order to do so, I will analyze the portrayal of intersexuality in the episode. In the process, I will argue that the portrayal of intersex people on medical TV dramas gains particular importance because of the discourses3 of medical authenticity that surround them and impart an aura of medical authority onto these shows. This effect, as I will show, is further enhanced by the performative enactment of medical professionalism in the show itself. Thus, House, M.D. is shown to be emboldened with the discursive power of modern biomedicine. Accordingly, I will argue that the depiction of intersex individuals gains special significance as the show can utilize its discursive power to either reaffirm or challenge their marginalized status and the heteronormative system that underlies it.

Although both intersexuality and House, M.D. have been the subject of numerous academic publications both within and outside American studies,4 the important connection between medical authority in cultural representations of modern biomedicine and intersexuality has remained largely unaddressed. It is precisely this gap in the current research on these two topics and their interrelation that my article strives to close. This is of particular importance considering the enormous reach of shows such as House, M.D. and the fact that “past research has revealed that biomedical models constitute a powerful means by which knowledges [sic] and ideologies, particularly about gender, race, and other measures of ‘normal’ bodies, are produced and circulated” (Gabbert and Salud II 209). Thus, medical TV dramas can play a pivotal role in either challenging or upholding current gender norms. This fact lends added significance to the portrayal of traditionally marginalized and medicalized groups such as intersex people.

In order to examine this issue, I will first outline my working definition of intersexuality and its related terminology. Next, I will consider whether medical TV dramas in general, and House, M.D. in particular, can be said to inherit the authority of modern biomedicine when it comes to presenting medical facts and in which ways this is established in the discourse surrounding the shows. Correspondingly, I will analyze the construction of medical authority within the narrative of the show itself by closely examining the pilot episode. On these grounds, I will then look at the representation of intersexuality within the episode in order to determine in how far it either challenges or reinforces heteronormative conceptions of gender and sex. In this context, this article utilizes the concept of heteronormativity in conjunction with Judith Butler’s concept of gender performativity, as well as Michel Foucault’s theory of the medical gaze. In this manner, the paper will demonstrate that rather than unfolding the deconstructive potential of intersexuality, the show reinforces heteronormative standards through its usage of medical authority to portray intersexuality as a pathological aberration.

Working Definition of Intersexuality and Related Terminology

Intersexuality is used as “an umbrella term that describes incongruity between external genitalia, internal reproductive anatomy, hormonal levels, and chromosomes” (Reis 373). There is a whole range of different intersex conditions with a multitude of different causes. According to Warnke, Dreger and Fausto-Sterling estimate that 1 in 500 to 1 in 2,000 children are considered intersex at birth (127). However, as Warnke points out, “these estimates increase if one includes infants with ‘unacceptable’ genitalia: for example, infants whose penises are considered too small or whose clitorises are considered too large” (127). The intersex condition that is of primary importance to this paper—i.e., the one that is featured in the episode under consideration—is called “Androgen Insensitivity Syndrome (AIS)” (Warnke 127). According to Reis,

[a] woman with androgen insensitivity syndrome (AIS), [...] has an XY karyotype, which typically would indicate maleness; however, her body, unable to process the androgens she makes, develops physically as a girl. Women with AIS look completely female, although they have internal testes. (374-75)

Traditionally, doctors assign intersex infants to “either male or female sex,” and then “carve the external genitals or internal organs to create the anatomy appropriate to that sex” (Warnke 127). The treatment is then supplemented with hormones “to ensure continuing conformity of the body to the assigned sex and their families usually receive counseling to help with proper, gender-based psychosocial rearing” (127). In the context of this medical paradigm, it is assumed that “a true sexed identity does exist—and that it must be restored” and thus “[g]enitals are described as being ‘unfinished’ or ‘incomplete’ and surgery offered as simply finishing a process of development begun in the womb” (Carroll 193).

Even though modern medicine allows doctors “to determine chromosomal and hormonal gender, which is typically taken to be the real, natural, biological gender,” this does not mean that this evidence is always the determining factor for the sex assignment. Instead, “biological factors are often preempted in physicians’ deliberations by such cultural factors as the ‘correct’ length of the penis and capacity of the vagina” (Kessler 12). These determining procedures are undertaken to ensure compliance with the heterosexual norm in that the ultimate decision regarding the child’s gender is based on whether the genitalia of a presumed male will be “capable of penetration” (106) and that of a presumed female is able to have “intercourse with a ‘normal-size’ penis” (58).

The medical treatment of intersexuality has been heavily criticized by intersex people (Preves 540). Organizations such as the ISNA have “lobbi[ed] to abolish all unnecessary surgery and ensure that what surgery is still performed is with the full understanding and consent of the intersexual individual involved” (Hird 352). This criticism, as Carroll points out, is based on the conviction that,

[s]uch interventions [...] constitute medically unnecessary cosmetic surgery on a subject unable to give consent[;] [...] such initial surgeries are often a prelude to lifelong medical interventions, whose side effects can include irreversibly impaired sexual function. (192)

These procedures, as Preves points out, are “founded on the belief that intersex is pathological” rather than on conclusive evidence of its effectiveness. She furthermore notes, drawing on previous scholarship, that these procedures are often designated as preventative in that “intersex is also seen as potentially disease causing, as evidenced by the emergency gonadectomies performed to prevent cancer” (524-25). Hence, she observes, “[b]odies that are sexually ambiguous challenge prevailing binary understandings of sex and gender. Individuals who are intersexed have bodies that are quite literally queer” (523). Agreeing with Butler, she concludes that “[t]he impetus to control intersexual ‘deviance’ stems from cultural tendencies toward gender binarism, homophobia, and fear of difference” (524). In a similar vain, Reis argues, “intersex bodies have been scrutinized and pathologized, based on the social anxieties about marriage and heterosexuality, rather than on medical necessity” (375). Likewise, Carroll remarks, “[i]ntersexuality demonstrates both the indeterminacy of ‘sex’ as a category [...] and the normative violence to which deviant bodies are subject” and argues that “the medical and surgical management of intersexed bodies can be considered symptomatic of a heteronormative imperative” (187).

Intersexuality is of major interest to proponents of queer theory as they set out to question the traditional “‘sex’/‘gender’ binary”5 and the underlying heteronormative assumption that there are only two genders that are attracted to each other (Hird 348), as well as the accompanying idea that “sex equals penis-in-vagina intercourse, [and] that ‘family’ constitutes a heterosexual couple and their children” (Clarke et al. 120). In this context, heteronormativity constitutes “the perceived reinforcement of certain beliefs about sexuality within social institutions and policies” (120).

Judith Butler, one of the most prominent critics of the sex/gender distinction and its heteronormative roots, asserts that “[t]here are no direct expressive or causal lines between sex, gender, gender presentation, sexual practice, fantasy and sexuality. None of those terms captures or determines the rest” (“Imitation” 725). Consequently, Butler criticizes the distinction between sex and gender because it is merely established to conceal the fact that both are “effects of a specific formation of power” (Gender viii). She further argues that gender is not the cultural expression of a prediscursive, biological sex but rather it should be seen as the “very apparatus of production,” which brings about the idea of an objective sex that precedes culture in the first place (Gender 7). In this context, Butler considers “gender [...] [to be] a kind of imitation for which there is no original” (“Imitation” 722) and states it performatively produces the semblance of its own originality (i.e., sex) (722). However, this does not mean that Butler considers the biological category of sex to be redundant, but rather that she views it as a result of the cultural norm of gender (Bodies 1). Thus, for Butler, rather than being “a simple fact or static condition of a body,” sex is a cultural and “regulatory [norm]” which is constantly reproduced “through a forcible reiteration of those norms” (1-2).

For the following analysis, Butler’s theory has two important implications. First, rather than viewing intersexuality as an aberration of biological sex, it will be discussed as a violation of the cultural norms underlying our current understanding of sex that via the regulatory mechanism of biomedicine—or, in this case, its cultural representation—is forcibly made to comply with these norms. Second, although the common understanding of the category sex is presumed to be a cultural product of the gender system, I will nonetheless continue to differentiate between sex and gender throughout the course of this paper in order to reflect the distinction and relation between the two that informs certain presumptions in the episode at hand and culture at large. However, this does not mean that this paper shares this belief, but it instead explicitly understands sex as a special formation of power—on the basis of cultural presumptions of gender—that is connected to certain physiological properties of human bodies and is imposed on those that do not comply with its principles.

The Medical Gaze and the Discursive Construction of Medical Authority and Truth in House, M.D.

Medical Authority and the Reception of Medical TV Shows

In western society, medicine, its practitioners, and the hospital in which it is practiced have a special status in that they are given and are perceived to possess the unequivocal authority to define what constitutes an illness and how it may be remedied. This authority is the result of a process that took place “in the 19th and early 20th centuries, as medical discourse, hospitals, and medical education transformed into institutions built on scientific standards that elevated the authority and prominence of physicians” (Rich et al. 221). As a result of this process,

medicine has [...] obtained well-nigh exclusive jurisdiction over determining what illness is [...]. In the sense that medicine has the authority to label one person’s complaint an illness and another’s complaint not, medicine may be said to be engaged in the creation of illness as a social state which a human may assume. (Freidson 205)

Although Freidson concedes that “the layman may have his own ‘unscientific’ view of illness diverging from that of medicine,” he maintains that “in the modern world it is medicine’s view of illness that is officially sanctioned and, on occasion, administratively imposed on the layman” (206). According to him, this part of medicine’s status as “a profession” establishes “the official power to define and therefore create the shape of problematic segments of social behavior” (206). Similarly, Gabbert and Salud II—with reference to Giddens—assert that “modern Western biomedicine” is exemplary of an “expert system” in which “people depend on the technological expertise of strangers” (211).

Michel Foucault terms this specialized medical knowledge and examination that accompanies it the “medical gaze” (Downing 34), which “indicates a mode of medical perception that enables the physician to look through the patient to recognize the disease” (Rich et al. 222). By means of this medical gaze, the doctor is said to be able to “communicate directly with the disease rather than with the patient, who is understood now in his or her particularities only so that these may be abstracted and contextualized” (222). To accomplish this, the medical gaze “partitions the body into its components and essays an anatomy of disease” (Downing 34).

According to Freidson, this process of medical evaluation is similar to the way that “the judge determines what is legal and who is guilty” in that the physician holds the authority to ascertain “what is normal and who is sick” (206). In this context, he defines illness “as a type of deviation, or deviance, from a set of norms representing health or normality” (207). As such, he maintains that “the concept of illness is inherently evaluational” and thus the practice of medicine represents “a moral enterprise like law and religion, seeking to uncover and control things that it considers undesirable” (208). However, as he points out, unlike law and religion, medicine “is believed to rest on an objective scientific foundation that eschews moral evaluation” and its conception of illness thusly appears to “constitute a physical reality independent of time, space, and changeable moral evaluation” (208). At the same time, Freidson rightly states, “[i]n human society, naming something an illness has consequences independent of the biological state of the organism” (208). Therefore, he concludes:

Illness as such may be biological disease, but the idea of illness is not, and neither is the way human beings respond to it. Thus, biological deviance or disease is defined socially and is surrounded by social acts that condition it. (209)

This medical authority is also transferred to the fictional representations of modern biomedicine in medical TV dramas. “Numerous studies have noted [...] [that] viewers use entertainment programs as a basis for their knowledge about medicine,” which demonstrates their trust in the medical accuracy and authority of these shows (Strauman and Goodier 32). One survey on the impact of the immensely popular medical TV drama ER showed that

about one in three [viewers] said that information they picked up from watching this fictional show helped them make real health care choices or decisions. About one in seven said they had contacted a doctor because of something they saw in the show. (Holtz 5)

Moreover, Holtz notes that medical shows have also been proven to have an educational effect in that “[a]t least twice during the long run of ER, health education researchers worked with the show’s writers to insert relatively unknown medical facts into the plots,” and combined these with national surveys that measured the impact this information had on viewers (6). One of these studies examined the effect of the inclusion of the “morning after pill” and “indicated that awareness of this sort of emergency contraception rose from about half of ER viewers before the episode aired to two-thirds of them a week after the show” (6). This reveals not only the significant effect that these shows can have on the medical knowledge of their audiences but also the tremendous trust viewers place in these reenactments of modern biomedicine.

Holtz admits that there are no similar studies for House, M.D., but sees little indication that it is any less effective (7). Although he notes that “[v]iewers know that prime-time dramas such as House are not intended as documentaries” (3), they still “expect that the plot twists and turns will contain basic elements of real medicine” (4) and “trust that the diseases, symptoms, tests, and treatments will contain essential elements of reality” (4). The show’s creators are aware of these expectations and they themselves emphasize the importance of medical accuracy for the show’s production; an assessment which Holtz bases on an interview he conducted with Lawrence Kaplow, one of the producers and writers, in which the latter remarked: “Absolutely. Otherwise you become a fantasy. Sure, we take liberties, but those liberties are still factually based” (4). In order to accomplish this level of accuracy and authority in the viewers’ eyes, the show’s writers, similar to those of ER, “not only [...] consult with experts and browse the medical literature for strange and interesting cases, but there are also medical experts on staff, including writer David Foster, M.D.” (7). Additionally, the writers of House, M.D. also consult with medical experts of “the Hollywood, Health & Society program of the USC Anneberg Lear Center” to further ensure the accuracy of their program (8-9). As if this was not already enough to convince its viewers of its medical authority, the show also “provid[ed] links to [medical] online resources from the official House Web site” (9) and in the context of medical education, the show has even been used in classes at universities, e.g., in a course by Professor Dr. Jürgen Schäfer at the Philipps University of Marburg in Germany (“Neues”).

All of this proves that viewers greatly trust in the information medical dramas such as House, M.D. present and that the creators invest substantial resources to maintain and nourish this trust. Combining this with the shows’ medical authority puts the creators in a position to make authoritative statements about the medical conditions which they depict. Concerning House, M.D., it is not only the discourse of medical authority surrounding the show’s production that is responsible for its perceived medical authority but also the way in which medical authority is enacted in the show itself. It is precisely this aspect that will be considered in the following section.

Narrative Construction of Medical Authority and the Medical Gaze in House, M.D.

The title sequence of the pilot already establishes the connection between House, M.D., modern biomedicine, and the medical gaze by showing a stylized scan of a human skull, which fades away to reveal the face of Dr. Gregory House, who seemingly scrutinizes the image; his face is then overlaid with the title of the show (“Pilot”). This creates the impression that the viewer observes House from the other side of an X-ray illuminator while House is analyzing the scan—i.e., practicing the medical gaze. In the opening credits6 of the other episodes, the emphasis on medical imaging is even more prominent. These credits feature not only the same CAT scan sequence but also highly stylized models of human skulls with their brains exposed to the observer, animations suggestive of neural networks, X-ray images of a human torso, other scans of the human skeleton, and numerous drawings of different parts of the human body (“Skin Deep”). The prominence of medical imaging in the opening “point[s] to the significance of reasoning in the formula of the show” (Włudzik 231). Even more crucially, the prominence emphasizes the importance of medical imaging technology in the show and connects it to the legacy and authority of modern biomedicine. In fact, the title sequence seems to suggest that this show, unlike other medical dramas, is about ‘serious,’ i.e., high-tech medicine.7

The importance of medical equipment and medical knowledge is also emphasized by its excessive use throughout the pilot episode and the entirety of the show’s eight seasons. Correspondingly, the patient is not only subjected to a routine blood test, to a CAT scan, a contrast MRI, experimental treatment with steroids, neurological tests to confirm that she has not suffered any brain damage as a consequence of a seizure and cardiac arrest caused by the steroid treatment but also, and lastly, to an X-ray (“Pilot”). Thus, while most patients might only have to go through one or two of these tests, the extreme cases that House treats are regularly subjected to a whole series of expensive and sometimes dangerous tests. The importance of medical technology is further underscored by the fact that

the episodes, rarely if ever, give attention to illness prevention or out-patient treatment; instead the show revolves around the state-of-art medical equipment and visualising techniques that make the final diagnosis possible. (Włudzik 233)

Consequently, these medical technologies “serve as the ultimate evidence” and as the basis for the team’s process of differential diagnosis (Włudzik 233).

The medical authority of House himself is stressed when his colleague and friend Dr. James Wilson asks him to consider a case he was unable to diagnose, and he refers to House as “a renowned diagnostician” or when Dr. Lisa Cuddy, Dean of Medicine and the hospital’s administrator, remarks that he “is the best doctor we have” (“Pilot”). Additionally, his repute is emphasized by Cuddy’s inability to fire him despite the fact that his “billings are practically nonexistent,” that he “ignore[s] requests for consults,” and that he is “six years behind on [...] [his] obligations to the clinic” because, as she informs him, “[his] reputation is still worth something to this hospital” (“Pilot”). In addition to his own medical prowess, which he continually confirms by the fact that “he saves patients no one else can save” (Burger 355), he also has, according to Wilson, “three overqualified doctors working for [him]” (“Pilot”).

Furthermore, the show utilizes “highly stylized recreations [sic] [of medical procedures8] and super-realistic computer animations” in which the camera seems to fly into the patient’s body to illustrate a diagnosis or to show the progression of an illness and its symptoms (Serlin 241). Similar to the use of “close-ups in the series,” Włudzik points out, with reference to Foucault’s concept of the medical gaze, that these animated sequences “could be interpreted as creating the impression of a penetrating medical gaze [...] that pierces through the skin and sees the purified and aestheticised body at work” (233). In the pilot, for example, the camera seemingly flies into a patient’s nostril, past her brain, into one of the arteries, and through her bloodstream only to be replaced by a CAT scan image of her skull, which then fades away to reveal House’s medical gaze upon it (“Pilot”).

The protagonist of House, M.D. has a very peculiar way of dealing with his patients in that he tries to avoid contact with them at all costs. For example, the pilot episode in which House does not directly interact with the patient, but rather uses his team as a mediator, demonstrates this behavior very well (“Pilot”). This is also exemplified in House’s reaction to Dr. Eric Foreman’s question, “[s]houldn’t we be speaking to the patient before we start diagnosing?” (“Pilot”). House replies by asking whether she is a doctor and then informs Foreman and the rest of his team: “Everybody lies” (“Pilot”). Moreover, Dr. Allison Cameron, another member of the team, elaborates on this, remarking: “Dr. House doesn’t like dealing with patients.” When Foreman retorts: “Isn’t treating patients why we became doctors?” House responds sarcastically, “[n]o. Treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable” (“Pilot”). Foreman questions this by remarking: “So you’re trying to eliminate the humanity from the practice of medicine?” House answers: “If we don’t talk to them, they can’t lie to us, and we can’t lie to them. Humanity’s overrated” (“Pilot”). According to Włudzik, House’s approach to patient care with its focus on distrust “aptly summarises the gist of the plot, as both patients and their bodies are liars and his role as a doctor is to find out the truth about them” (235).

Through the way in which House treats his patients, he constantly reaffirms his medical authority and, according to Włudzik, “is depicted as a mythical medical hero able to come up with the correct diagnosis at any time” (231). One instance in the pilot episode, when House’s patient refuses to accept his diagnosis and suggested treatment, illustrates this very well. Before accepting further treatment, the patient demands visual proof of the tapeworm in her brain—House’s ‘perfect’ diagnosis. Rather than yielding to his authoritative statement—“[w]hen you’re all better, I’ll show you my diplomas”—she continues to question it by pointing out his previous incorrect diagnoses (“Pilot”). Ultimately, the patient does not change her mind before Dr. Robert Chase, another member of House’s team, suggests using an X-ray to diagnose the patient, which proves House’s diagnosis, reasserts his medical authority, and reemphasizes his exceptional diagnostic skills.

Inspired by House’s example, his team also withholds information from their patients and only informs them of their current diagnosis and the kind of treatment they are performing after repeated questions (“Pilot”). This represents a general tendency in House, M.D., i.e., patients are assumed to be medically incompetent and a danger to themselves, as well as an obstacle to the diagnoses and their treatment. As such, they are not consulted prior to treatment, are only given partial information, and are lectured if they should dare to question their doctors or modern medicine in general. This becomes evident when House reprimands a mother who has withheld asthma medicine from her son due to her concerns regarding “children taking such strong medicine so frequently” by informing her that “[y]our doctor probably was concerned about the strength of the medicine, too. She probably weighed that danger against the danger of not breathing.” He then lectures her on asthma only to conclude “Forget it. If you don’t trust steroids, you shouldn’t trust doctors” (“Pilot”). This is exemplary of the show’s tendency to portray patients “as separated from their bodies, unable to understand their complicated signals and in a desperate need of a professional medical intermediary” (Włudzik 234).

As a result of the patients’ ignorance of the messages their bodies are sending, House and his team have to force them “to confess their illness, using any available means from diagnostic technology to moral blackmail” (Włudzik 233). The doctors here are seemingly justified by “the usual critical state of their patients” (233). In this context, House’s “devotion to finding a cure justifies all his wrongs and sharpens his sense of vocation as a doctor” (234). As such, House embodies the ideal practitioner of the Foucauldian “biomedical model” in which “doctors are supposed to be competent, caring,9 omniscient, and omnipotent managers in the production of health” (Gabbert and Salud II 210). However, as Gabbert and Salud II point out, doctors “make mistakes, guess, or are simply incompetent” and thus “[subvert] the ideological model in real life” (210). Nevertheless, even though House does make mistakes and does base his medical diagnoses on educated guesses, he is never portrayed as incompetent and his mistakes appear to be a natural byproduct of his diagnostic process, or as Strauman and Goodier put it:

Notably, even when House’s diagnosis is wrong, his process is proven correct. House often defends his decisions, arguing that by finding out what something is not (and often worsening the patient’s situation), he and his team are closer to figuring out the mystery. (38)

This diagnostic process is by and large shown to be remarkably successful in that “he [House] loses very few patients given the ‘unsolvable’ cases he and his team often confront” (Burger 355). Strauman and Goodier even go so far as to argue that “House’s accuracy as a diagnostician and scientist provides a firm foundation for his role as the ultimate authority figure” (38).

Additionally, the fact that his “technocratic evidence-based” practice of medicine, as Włudzik puts it, “enjoys improbably high rates of success on the show,” underscores his medical authority, and “[inspires] an unswerving belief in progress and [the] power of medical knowledge” in the shows viewers (237). As such, she argues, “House, M.D. is aimed at recognizing and reducing uncertainties, instead of identifying them as a valid part of the postmodern medical world” (242). Włudzik concludes that “House, M.D. can be seen as a consolatory attempt to act out the modernist fantasy of medical technocracy” (243). It is the aim of the remainder of this article to ascertain whether this assessment also applies to the show’s portrayal of intersexuality and, if so, how the show utilizes its medical authority to reinforce heteronormativity and the pathologized status of intersexuality.

Intersexuality in the Episode “Skin Deep”

In the 2006 episode “Skin Deep,” House, M.D. tackled the issue of intersexuality for the first time. It was certainly not the first medical TV drama to do so, both Chicago Hope and ER had already done so during the 1990s (Tropiano 52), and this would not be the last time as the series’s writers would incorporate intersexuality into another episode called “The Softer Side” in 2009. Nonetheless, as indicated above, this episode was met with particularly harsh criticism by representatives of the ISNA, who remarked “that such wrongheaded and insensitive portrayals are harmful to individuals with Disorders of Sex Development and to our work to better educate the public” (Herndon). This section of the present paper will closely examine the representation of intersexuality in the episode to examine whether it either challenges or reinforces heteronormative notions of gender and sex.

Throughout the episode, there are several instances of sexism, underscoring that the show’s portrayal of intersexuality is deeply informed by heteronormativity. In the beginning of “Skin Deep,” the supermodel Alex collapses on the catwalk after inexplicably attacking another model. As soon as Alex is in the hospital, Cuddy introduces the case to House with the words: “Teenage supermodel. Presented with double vision, sudden aggressive behavior, cataplexy,” only to be interrupted by House who takes the file out of her hand, remarking: “You had me at ‘teenage supermodel’” (“Skin Deep”). Shortly afterward, House uncharacteristically heads straight for Alex’s room and, upon entering, immediately begins flirting with her: “Wow. You should be a model. Are you really fifteen?” Additionally, when House leaves Alex’s room, he is immediately accosted by Cameron with the question: “Since when do you voluntarily go see patients?” House replies in an exasperated voice: “Have you seen her?” (“Skin Deep”). These examples illustrate that House’s decision is not based on his medical interest in the case, but rather on the fact that Alex is a supermodel, i.e., on his sexual interest.

In the next scene, House and his team meet in the diagnostic room to discuss their findings. Here it becomes clear that House and his team do not take the case seriously. They objectify Alex by focusing only on her appearance. In the beginning of the discussion, the majority of the team comes to the conclusion that her symptoms must be the result of a heroin addiction because the tests revealed that she took heroin. Only Cameron objects to this idea, pointing out that “[a] positive test means she tried it once. It doesn’t mean she’s an addict.” However, the rest of the team remains convinced of their diagnosis, seeing the fact that she has never menstruated as a consequence of her addiction. While Cameron maintains that this could also be an indication of bulimia “[o]r her age. Some girls don’t start ‘till their mid-to-late teens,” House remarks: “Evidence to the contrary, the rounded hips. The perfectly-sculpted bountiful breasts.” When Chase suggests that her breasts might be the result of implants, House bets that “those love apples are handcrafted by God.” At this point, Cameron has to remind the team to discuss the patient’s health rather than her breasts and that “[e]ven if she is an addict, a lot of her symptoms [...] could be neurological.” In the end, House wants to rule out the possibility that her current condition might be masking other health issues and orders his team to put Alex in a medically induced coma, performing a rapid detox procedure on her (“Skin Deep”).

The following process reveals that Alex’s condition was not the result of her heroin addiction, which forces House and his team to come up with a new diagnosis. Subsequently, House proposes that Alex is suffering from Post Traumatic Stress Disorder (PTSD) due to being sexually abused by her father, remarking: “Show me a woman on heroin who looks like that, and I’ll show you a woman who’s been sexually abused.” When his team remains unconvinced, House orders them to perform an MRI and a lumbar puncture to rule out brain damage and confirm his diagnosis (“Skin Deep”). Here, House adopts a mode of medical reasoning that is largely based on Alex’ supposed desirability—i.e., his male rather than his medical gaze.10

While his team is performing the tests, House personally takes it upon himself to confirm his diagnosis by confronting the father and coaxing him into confessing that he had sex with his daughter. He offers him doctor-patient confidentiality and tells him that her life may depend on this information. Consequently, House triumphantly announces to his team that he was right but is told that the evidence they discovered in their tests reveals that, as Foreman puts it: “You’re wrong about PTSD and I was wrong about hypoxic brain injury” (“Skin Deep”). As a result of this, the team is forced to come up with a new diagnosis. Foreman suggests that a series of neurological problems such as “viral encephalitis” and “Creutzfeldt-Jakob disease” could explain their finding that she has “elevated proteins in her CSF” (Cerebrospinal fluid). To confirm their diagnosis, House orders them to perform a brain biopsy.

However, the biopsy fails to confirm any of their diagnoses. Consequently, Foreman suggests possible candidates such as “[n]euronal ceroid lipofuscinosis [and] Heller Syndrome,” but, as House points out, “[w]e can’t test for any of those things.” Instead, he suggests that her symptoms might be the result of a tumor, noting, “If she has cancer anywhere in her body, she could also have paraneoplastic syndrome, which could be causing antibodies to attack her brain. Antibodies are stupid that way.” When Foreman states that “paraneoplastic syndrome’s awfully rare in a fifteen-year-old,” House counters his objection by remarking: “It would explain the aggressive behavior, the cataplexy, the memory loss, even the twitching. It’s perfect” (“Skin Deep”). Despite Foreman’s insistence that “[t]here’s no test for paraneoplastic syndrome,” House comes up with a test to confirm his diagnosis. Even though, as Wilson observes, they have “checked everything,” they are unable to find any signs of cancer, and the only anomaly they discover is that her ovaries seem to be “undersized” (“Skin Deep”). Therefore, the team is forced to return to House’s diagnosis that she has PTSD but ultimately disproves this diagnosis as well (“Skin Deep”).

In the meantime, House has an epiphany while treating a male patient who is suffering from sympathetic pregnancy. He remarks that the patient is a “perfect man” in that he is “[a] woman.” At this point, House realizes that the inverse might be the case with Alex. Thus, when Cameron asks if he thinks it is hormonal, House remarks “I’m thinking she’s the ultimate woman.” For this reason, he schedules an MRI to confirm his diagnosis, which it ultimately does. As this examination reveals Alex’s intersexuality, a significant change in House’s behavior toward Alex can be observed immediately. While examining her, he stops being flirtatious and instead repeatedly tells her to stop talking and is seemingly annoyed with her noncompliance (“Skin Deep”). This once again shows that his former favorable treatment of Alex was solely motivated by his sexual interest in her—which has been troubled by his final diagnosis—and reveals the sexist underpinnings of his behavior throughout the episode.

When House informs Alex and her father of his final diagnosis, he clearly privileges medical evidence—such as the results of Alex’s DNA testing—over her own sense of identity. Upon entering Alex’s room, House declares that they have found the tumor. When her father asks him if she has cancer, House corrects him by stating that technically “‘he’ has cancer on ‘his’ left testicle.” When Alex incredulously remarks that she does not have testicles, her father similarly asserts: “She’s not a guy.” House overrules both of them with his medical authority by remarking: “His DNA says you’re wrong” (“Skin Deep”). Consequently, House begins to lecture them while computer animations are used to illustrate his explanations to the viewer:

You’ve got male pseudohermaphroditism. You see, we all start out as girls and then we’re differentiated, based on our genes. The ovaries develop into testes and drop. But in about 1 in every 150,000 pregnancies, the fetus with an XY chromosome [sic], a boy, develops into something else, like you. Your testes never descended, because you’re immune to testosterone. You’re pure estrogen. Which is why you got heightened female characteristics, clear skin, great breasts. (“Skin Deep”)

He ends this explanation by remarking that “[t]he ultimate woman is a man.” When he sees the distraught look on their faces, he follows it up with the comment: “Nature’s cruel, huh” (“Skin Deep”).

However, although House does not seem to be aware of this, it is not nature, but rather heteronormative culture—represented and enforced by House—that is cruel, because it is culture that socially defines intersexuality as a deviant aberration from the heterosexual norm (see Kessler 12, 106; Freidson 209). In this manner, Alex’s intersexuality troubles House’s sexual interest in her and, with it, his heterosexuality. When the devastated Alex gets out of bed and takes off her hospital gown, exclaiming: “No! You’re wrong! I’m a girl! Look at me! How can you say I’m not a girl? See, they’re all looking at me, I’m beautiful!” he simply replies in a patronizing tone: “That anger. It’s just the cancer talking. Put your clothes back on. We’re gonna cut your balls off. Then you’ll be fine” (“Skin Deep”).

As these scenes show, the presentation of intersexuality in this episode does nothing to challenge its marginalized status, but rather contributes to its marginalization. House not only denies Alex’s gender identity by proclaiming that she really is a man—thereby enforcing the gender binary—but also overrules her protest by using his medical authority and the seemingly incontrovertible evidence of DNA testing (Herndon). In doing so, the show uses its medical authority to reinforce the idea that medicine has the ability to unequivocally determine a person’s sex and that this defines the person’s gender identity. Although Alex’s desperate protest could have problematized House’s actions, her objection is essentially muted by the fact that he dismisses it as merely a symptom of the cancer and thus of her ‘abnormal’ status as an intersex person. Furthermore, House’ suggestion that her emotional turmoil will be fixed by cutting off her “balls” delegitimizes her reaction (“Skin Deep”). This not only denies her any agency over her own body and identity but also serves to pathologize her—and by association intersexuality in general.

Moreover, House, as Herndon points out, also “grossly underestimate[s]” the frequency of intersex births as 1 in 150,000. Indeed, as she argues, a more accurate estimation would be 1 in 1,500. In doing so, House contributes to the erasure of intersexuality, which is common in modern medicine practice. In addition, the presentation of AIS women as an exotic species of “perfect wom[e]n,” who are, in the logic of the episode, eventually ‘unmasked’ and ‘revealed’ to be men, serves to further pathologize them (“Skin Deep”). House’s frustration and disappointment after discovering that his ‘perfect woman’ really is a man—at least according to his definition—also shows how Alex’ status in between gender categories urges him to reaffirm these categories and, with them, his sexual orientation. The fact that House presents his diagnosis in such an insensitive manner has immediate repercussions on the audience and can thus be viewed as one of the most problematic aspects of the portrayal of intersex people in the episode. Such a representation might inform how real-life intersex people will view themselves (Jane Goto qtd. in Herndon) and expect to be treated should they decide to seek medical assistance.

Overall, the fact that the show’s first case involving intersexuality directly links the patient’s health problems to Alex’s intersex condition shows that the episode establishes a causal link between intersexuality and illness, and thus contributes to its continuing pathologization. On a positive note, the fact that Cuddy problematizes House’s categorization of Alex as either “she” or “he” at least tentatively critiques House’s denegation of Alex’s gender identity. Similarly, the fact that House has ordered psychological care could be seen as positive, even though he himself is responsible for making it necessary in the first place (“Skin Deep”). However, the show utilizes its medical authority to reinforce the gender binarism and, along with it, the already marginalized status of intersexuality.

Conclusion

In the course of this paper, I have shown that medical TV shows like House, M.D. are imbued with considerable medical authority as a result of the discourse of medical authority that surrounds them. It has also been argued that they promote this perception by means of cultivating an image of medical professionalism informed by Foucault’s conception of the medical gaze that is able to penetrate the body to reveal a truth about it. Incorporating medical imagery and technology that seemingly allows the doctors to make definitive diagnoses and eliminate uncertainty also establishes a sense of medical professionalism. Additionally, the show highlights House’s authority by portraying patients as incompetent and by presenting House as a medical genius with the ability to solve seemingly hopeless cases.

Based on this premise and with the help of Butler’s conceptualization of gender, the representation of intersexuality in the episode has been analyzed to show how House, M.D. uses its medical authority to reinforce the heteronormative pathologization of intersexuality. The episode’s portrayal of intersex people establishes a problematic link between intersexuality and illness that contributes to its pathological status. Additionally, it has been argued that the way in which House questions Alex’s gender identity—and rejects her claim to femininity by using the discursive power of DNA testing against her—further substantiates the notion that medicine can identify the purported ‘real sex’ of a person and that this sex should be the determining factor in a person’s gender identification. The fact that House considers Alex’s outrage at this diagnosis to be due to her cancer further legitimizes his claim and invalidates her own gender identification. Finally, House’s insensitive way of presenting his final diagnosis not only emphasizes the pathologized status of intersex individuals but may even deter some of them from seeking medical help. In conclusion, it can be said that rather than unfolding the deconstructive potential of intersexuality, its portrayal on the show is used to reinforce heteronormativity and to present intersexuality as a pathological aberration that has to be treated to comply with heteronormative standards.

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Notes

1Włudzik herself refers to the House, M.D. Guide to the Show.

2Or, to be more precise, that she has Androgen Insensitivity Syndrome (“Skin Deep”).

3Throughout this article the term discourse is used in the Foucauldian sense in that it is intended to convey “not just spoken language but the broader variety of institutions and practices through which meaning is produced” (Sturken and Cartwright 102). This means that it is assumed to represent “a group of statements that provide a means for talking (and a way of representing knowledge) about a particular topic at a particular historical moment” (105). It is also important to understand, as Sturken and Cartwright point out, that “[c]ertain kinds of knowledge are validated in our society through social institutions such as [...] the medical profession [...] while other kinds of knowledge may be discredited because they do not carry the authority of institutional discourse” (109).

4For example, Rachel Carroll discusses the representation of intersexuality in Jeffrey Eugenides’s Pulitzer Prize-winning novel Middlesex (187).

5In this binary, sex is understood to be rooted in biology and gender represents “the practices of femininity or masculinity in social relations” (Hird 348).

6The opening credits are used for all episodes except the pilot.

7As Włudzik states—with reference to Jensen and Witter—other medical shows “usually are more relationship-oriented” (231).

8These re-creations replace the “snippets of actual filmed surgery” that other shows like ER have used in the past to illustrate a procedure (Serlin 241).

9As already noted, House’s caring is limited to curing the patients and for the most part excludes direct interaction with them. In fact, a number of scholars as well as the characters in the show and critics of the show note that House seems to be “more interested in the puzzle of diagnostics than in the patients themselves” (Burger 357).

10The term “male gaze” was first introduced by Laura Mulvey in her 1975 essay “Visual Pleasure and Narrative Cinema.”