Revisiting the Claims of Past Medical Innocence and Good Intentions

Round 1

Reviewer 1 Report

This paper provides an original and significant addition to the literature. Congratulations on a strong paper. I look forward to seeing it published.

The writing style is dense and sometimes abstract, so my comments below aim to improve readability and clarity. 

Line 4: “non-consensual” - a standard clinical response is that parents consent, as is usual for surgery on children. Suggest rephrase to identify urgency first, and lack of personal informed consent.

Line 6: the idea that adults’ experiences of childhood treatments reflects past practices reads like a truism, suggest referring to “obsolete” past practices to make a clearer point. 

Line 12: “when justification talk has not been produced” suggest the more precise “is not documented”

Lines 15-16: The sentence “Many clinicians anticipated the reluctance of peers to clitoridectomy.” seems out of place, suggest reconsidering inclusion in the abstract, or shifting to the end and adding more explanation

Line 21:”Medical professionals invested in normative management of sex characteristics of children” - suggest adding a couple of sentences explaining what the medical management is, and rephrasing “invested”. Readers may not be clear on these issues

Line 58 “to the ‘many years ago’ period” is unusual wording, perhaps refer to “historic” or simply “documented past practices” 

Lines 83-92: recommend making an explicit statement identifying the longevity of claims about differences between current and past practices. The evidence you have of historical claims is both fascinating and disturbing. You cite Carpenter 2024 who makes the statement that such claims have historically worked to stymie reform efforts

Materials and Methods section: suggest adding clearer reasoning for your selection of illustrative quotations. 

Line 176: suggest “documenting” or “illustrating” in place of “collecting”

Line 211: “be they sterilized by the unmarkedness of dominant 211

values or not” suggest rephrasing to improve clarity

Line 292: for precision, suggest “unexamined” in place of “undefined”

Line 294: “What the concerned individual would make of this function” - who the concerned individual might be is not sufficiently clear

Line 325: “founded claims”, should be “evidenced” or “wellfounded”? 

Line 441: consider simplifying “imperative of sex characteristics normalcy” to “imperative of sexual normalcy”

Line 452: consider “allowed or tolerated”

Line 559: this sentence calls for citations, or should be rephrased “I am not the first intersex individual to come to that conclusion, though, as it circulates in the community.”

Discussion section: 

consider adding thematic sub-headings to improve readability

Line 724: “They are dissolved into other social actors who enjoy more acknowledgement than they do.” consider rephrasing to improve clarity

Discussion: Consider referencing a paper on culpable complicity by Eliana Peck and Ellen Feder, which may be useful in framing some of your arguments in the discussion: 

Peck, Eliana, and Ellen K. Feder. 2017. ‘Institutional Evils, Culpable Complicity, and Duties to Engage in Moral Repair’. Metaphilosophy 48 (3): 203–26. https://doi.org/10.1111/meta.12238

Also at:

Peck, Eliana, and Ellen K. Feder. 2018. ‘Institutional Evils, Culpable Complicity, and Duties to Engage in Moral Repair’. In Criticism and Compassion, edited by Robin S. Dillon and Armen T. Marsoobian, 171–92. Oxford, UK: John Wiley & Sons, Ltd. https://doi.org/10.1002/9781119463030.ch11

See comments in previous section

Author Response

Thank you very much for the revision. Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the chance to read your paper, I found it interesting and engaging. Overall there are very few 'specific' things to note, rather some  overall points that I think could aid the work. 

The first point is that epistemic injustice is referred to as a way of interpreting and approaching the analysis on line 248, however notions of epistemic injustice do not appear again in the manuscript. This either needs to be removed or more properly integrated into the analysis. I can see how the resulting analysis may have been informed by notions of epistemic injustice, but the author(s) do not make this clear.

I think the methodology section could also be made clearer. There is brief talk about a three step endeavour and drawing on a book project, but the analysis steps made are less clear in a very long paragraph on P5. Some work needs to be done here to more clearly articulate the analytic steps taken and the method of analysis. 

I also think there is some contextualisng work to be done to bring the audience along on the narrative and analytic journey.

Firstly, is that I think the historical analysis is excellent but it lacks a broader historical context. For example I think readers not familiar with the history of intersex could dismiss this by saying that surgeons over this particular time period were not overly considerate of any patients, especially children. I think acknowledging this context is important. For example we know that doctors tended to behave like 'gods' (and still do to some extent) over this time period, so what is it that makes this especially egregious in the case of intersex management? An acknowledgement that this behaviour existed more generally as well is important to contextualise the narrative. 

On a related note this is also important for the treatment of children - both by parents and by the medical community. For example it was the norm for children to go to hospital and not be seen by parents regularly during their stay. Children's rights, are a very recent phenomenon - the UN Convention on the Rights of the Child wasn't created till the late 1980s. The notion of children's rights is a relatively new phenomenon. The story needs to be contextualised against this as well. This is not a way of condoning what was done at all, but it contextualises a broader disdain for the rights of all children, and therefore this is a deeper disdain for intersex children. For example, the author rightly talks about past claimed benevolence in the instance of the removal of Indigenous children in Canada (which was a great comparison). I think the author(s) could also use this as an example of the sheer disregard for children's rights. 

Finally it would be nice to see the author(s) separate some of the discussion off into a final 'concluding thoughts' section. This links to my point in the below section about being kind to readers and taking them by the hand. A 'conclusion' or 'concluding thoughts' section allows the reader to pause and understand that these are the key points the author(s) wants us to take away. 

The article is well written but the language used is highly academic and in places hard to read. There are some extremely long paragraphs that can 'weary' the reader. To me this read like an author deeply immersed in, and excited by, the analysis. This is to be commended, however at times the wording and language used is very dense. I wanted to join in the excitement, but I needed the author to be a little more 'kind' in taking the reader by the hand and stepping them through the analytic points a little more. For example lines 210-255 is a very long paragraph and needs reworking to be more accessible (and this links to the above about making the methodology clear). As is the paragraph starting on p6. These are two of the clearer examples of where things could be reworked to aid the reader, but I do think the author(s) need to reconsider the whole article with a 'reader-friendly' angle. A more reader-friendly article is also likely to gain a wider audience.

A small note that the word Indigenous should be capitalised as a matter of respect and epistemic (even grammatical?) justice. 

Author Response

Thank you very much for the revisions. Please see the attachment. 

Author Response File: Author Response.pdf