Analysis Human Rights

The Biology of Gender, and When (if Ever) Children Should Be Given Sex Reassignment Surgery

Martha Kempner

The first words uttered after a child is born are often “It's a boy!” or “It’s a girl!” But sometimes doctors don’t know exactly what to say. How does this happen, and what should parents and doctors do?

Last week, parents in South Carolina filed a lawsuit against the state on behalf of their 8-year-old adoptive son, known as M.C., who was born with both male and female genitalia and was given sex reassignment surgery as a toddler when he was a ward of the state.

In a recent Rewire article, Jessica Mason Pieklo explored the legal issues in the case. Here, I want to look at the myriad other gender-related issues a case like this raises. There are biological issues (How do some babies come to be born with male and female genitalia?), sociological issues (Is our gender born or made, and is it possible to raise a child, even a very young one, in a gender-neutral way?), and psychological issues (What’s in the best interest of a child in this situation?).

Biological Sex

We don’t know the precise medical condition M.C. has, but there are a number of ways he could have been born with genitalia and reproductive organs that at least appear to be both male and female. At one point, M.C. would have been called a hermaphrodite, though that would likely have been inaccurate as the term technically refers to someone who has both ovaries and testes. Within the past few decades the word intersex was introduced as a way to describe individuals with these conditions. More recently, the term “disorders of sexual development” has been used, but some advocates feel this language only further marginalizes the identities of these individuals.

Whatever language we land on, it all starts with sperm and ova (eggs), which are known as gametes. They each carry 23 individual chromosomes that, when they come together, become the 23 pairs of chromosomes that make up our unique genetic identity. One of those pairs of chromosomes determines our biological sex. Ova always (or almost always—more on that later) carry one X chromosome, while sperm typically carry either an X or a Y chromosome. When they come together and everything goes according to plan, an embryo with XX chromosomes develops into a female, while one with XY chromosomes develops into a male.

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All fetuses start out with two undifferentiated gonads and certain homologous structures (structures that start out the same) that can become either male or female sex organs. It is up to the chromosomes to start the path toward male or female. Do nothing and the fetus will develop ovaries that begin to make estrogen. The homologous structures will then become a uterus, fallopian tubes, and a vagina internally. Externally they will develop to form the labia minora, labia majora, clitoris, and the vaginal opening.

Add something called TDF (testes determining factor), which is found on the Y chromosome, and the gonads will become testes and start making testosterone. The homologous structures in the fetus will then turn into the internal reproductive system (such as the Cowper’s gland, prostate gland, and seminal vesicles) and the external male genitalia (the penis and scrotum).

Though the majority of babies born will have followed one of these two paths, there are many points along the way where things can diverge.

Chromosomal Anomalies

Though each gamete is supposed to have only one sex chromosome, problems can occur during meiosis (the process of cell separation) that cause them to have more than one or none. This means that an embryo can begin to develop with too many or too few sex chromosomes. For example, Turner Syndrome, XO, develops when either the egg cell or the sperm cell does not have a sex chromosome at all. Individuals who are born with Turner Syndrome have external female genitalia and internal female reproductive organs (ovaries, uterus, and fallopian tubes), but the ovaries are not functional and do not produce estrogen during development. Klinefelter’s Syndrome, XXY, happens when an egg with two X chromosomes is fertilized by a sperm with a Y chromosome, or an egg with an X chromosome is fertilized by a sperm with both an X and a Y. These individuals will appear male when born, but some abnormalities, including small testes, a female pattern of pubic hair, poor muscle development, and a lack of facial hair, may begin to be noticed as the individual reaches puberty. Other combinations, like XYY or XXX, can cause issues after puberty such as infertility and irregular periods but exhibit no outward symptoms in childhood.

Hormonal Anomalies

While chromosomes set a fetus on the path toward its biological sex, how the fetus develops is also very much controlled by the hormones it is exposed to while in utero (and after birth) and how the body processes these hormones. When the hormones are not produced or the body can’t process them, the fetus develops along a different path.

For example, Androgen Insensitivity Syndrome (AIS) occurs when the body cannot process male sex hormones (known as androgens). When this happens in someone who is genetically male (XY), the testes will develop and produce testosterone, but because the body cannot process this hormone, the fetus will develop along a female path and will appear female when born with external genitalia that appear to be labia. The internal reproductive organs, however, will not have developed completely. The baby will be born with a shortened vagina and will not have a uterus. The baby will also have undescended testes, which will most often be located somewhere in the abdomen.

Another hormonal issue is called Congenital Adrenal Hyperplasia (CAH). It is a disorder of the adrenal glands (there is one adrenal gland located on each of our kidneys) which causes a buildup of androgens in a fetus and infant. If this happens in someone who is genetically male (XY), it can cause sex characteristics to appear too early. Genetic females (XX) with some forms of CAH will usually have normal internal reproductive systems (ovaries, uterus, and fallopian tubes) but may have an enlarged clitoris at birth. In some instances the clitoris may be so large that it is mistaken for a penis.

DHT deficiency is another common anomaly. Genetic males (XY) with DHT deficiency do not produce enough of a hormone called dihydrotestosterone (DHT) while in utero. Some babies with this deficiency are born with external genitalia that look female, while others are born with external genitalia that appear male but are unusually small (sometime called a micropenis). Still others will be born with what is called ambiguous genitalia, where it is hard to tell whether they are male or female just by looking.

A Rush to Judgement

The first words uttered after delivery are often “It’s a boy!” or “It’s a girl!” But what happens when these conditions make it so doctors don’t know exactly what to say? Such a diagnosis can be difficult for parents, and the path forward unclear.

As with many things in our society, there has historically been a rush to fix that which is not “normal.” In many cases this has meant that parents are told their infant needs to have surgery immediately to make their genitals appear more like an average clitoris or penis. In truth though, it has always been much easier to create labia and a vagina than it has been to create a penis (especially one that functions). Most of the time, therefore, doctors would recommend that parents surgically create female genitalia and begin to raise the infant as a girl regardless of the chromosomal sex or what hormones the infant was exposed to in utero.

This appears to be what happened to M.C. It is also what happened to Cheryl Chase, who later became an advocate for putting off genital surgery until a child is old enough to make their own decisions. Cheryl was born in 1956 with ambiguous genitalia—she had what could have been an enlarged clitoris or a micropenis and something that appeared to be a vaginal opening. At first doctors recommended that she be brought up as boy, so she went home from the hospital with the name Charlie. But her parents were concerned about the appearance of her genitals and consulted another team of experts when she was 18 months old. Based on the fact that she had a fairly normal vagina, these experts recommended surgery to make her external genitals look more female. She underwent a clitoridectomy and was sent home as Cheryl. Her parents never told her what had happened, though she remembers many unexplained surgeries and genital exams during her childhood. She also remembers not fitting in with the other girls: “I was more interested in guns and radios and if I tried to socialize with any kids, it was generally boys, and I would try to best my brother.”

Interestingly, the most famous test case of gender reassignment in children did not involve someone with a disorder of sexual development. Instead, the case involved identical twin boys who were born in 1965 with identifiably male sex organs. At eight months old they underwent circumcision because they were suffering from phismosis (a condition in which the foreskin will not pull back). There was a serious accident and one twin essentially lost his penis. At the time, doctors said they were unable to surgically give the child anything that looked or functioned like a real penis.

The parents turned to Dr. John Money, a pioneer in the field of gender and sex reassignment surgery. Money had a theory that gender is purely a cultural concept that comes from how kids are raised, especially early in their lives. He believed that infants are born as blank slates, and it is not until their parents and society imprint them with gender that they begin to see themselves as either male or female.

Money met with the parents of the infant (then named David) and assured them that if they allowed surgeons to construct external female genitalia and then raised the child as a girl, “she” would be capable of growing into a well-adjusted young woman. Money was particularly interested in this case because as an identical twin David came with a control group. If “she” could be successfully raised as a female while her brother (who had the exact same genetic make-up) was successfully raised as a male, it would go a long way toward proving Money’s blank-slate theory. The parents took Money’s advice, did the surgery, and proceeded to raise David as Brenda. Neither she nor her brother was told the truth about the situation.

For years, Money published papers about how well his gender experiment was going, and his research on the “John/Joan case” became the basis for his book, Man & Woman, Boy & Girl. It also made national news, including a full-page story in Time magazine. But the family tells a different story. The twins’ mother claims that the first time she put a dress on Brenda, the child tried desperately to pull it off. Brenda’s brother tells it this way, as quoted in an article for Healthy Place: “I recognized Brenda as my sister but she never, ever acted the part. She’d get a skipping rope for a gift, and the only thing we used it for was to tie people up, whip people with it.” He went on to say, “When I say there was nothing feminine about Brenda, I mean there was nothing feminine. She walked like a guy. She talked about guy things, didn’t give a crap about cleaning house, getting married, wearing makeup.” And as a teen she refused to go ahead with the surgery that would have created a full vagina.

As soon as Brenda learned the truth, at the urging of a psychologist who saw her as near suicidal, she began once again to live as David. When the real result of the “John/Joan” case became public in the mid-1990s, David was a 31-year-old man and married to a woman. At the time, he said he was happy living as a man but acknowledged that getting there was not easy and that he had contemplated suicide a number of times. Sadly, this happiness did not remain; in 2004 David Reimer took his own life.

Today’s Thinking

Based on cases like Cheryl Chase and “John/Joan,” the prevailing wisdom today suggests that rushing into surgery, which has permanent repercussions, for purely cosmetic reasons is a bad idea. It is important to note that some conditions do require early surgery for functional reasons, such as separating the vagina from the urethra, or safety reasons, such as removing testes located within the abdomen as they can become cancerous. But in most cases the surgeries that these children undergo—like the one that M.C. had—are about appearance.

A recent consensus document written by the Lawson Wilkins Pediatric Endocrine Society in the United States and the European Society for Pediatric Endocrinology advises parents and physicians to take it slow and not treat the birth as a medical emergency that requires immediate intervention.

Instead, the guidelines suggest that every infant be assigned a gender shortly after birth based on the diagnosis, genital appearance, surgical options, needed for lifelong replacement therapy (such as estrogen shots), potential for fertility, and the views of the family and culture. In our pink and blue society, it is not possible, nor is it advisable, to attempt to raise a child without gender. The idea, however, is that this without surgery this gender assignment can change if it turns out to be inconsistent with how the child feels as he or she grows up. This allows the child (most likely as a teen or an adult) to make the ultimate decisions about gender and genital appearance.

While this approach clearly makes the most sense, the waiting game must be very difficult for parents who will likely have many concerns about whether their child will accept him/herself and how he/she will be treated by others if they look different (think potty training in preschool or high school locker rooms). In M.C.’s case, the guardians may also have worried that the child would not be adoptable without a clear gender and “normal” genitalia.

M.C. is very lucky that he found parents who are strong advocates for his right to be who he wants to be. Hopefully their efforts can help young people and parents who are facing these issues make these difficult decisions as painlessly as possible.

Culture & Conversation Media

From ‘Mouseburger’ to Media Icon: Bio Traces Rise of Cosmo Editor Helen Gurley Brown

Eleanor J. Bader

Helen Gurley Brown was a publishing giant and pop-culture feminist theorist. But according to her latest biographer, she was a mass of insecurities even as she confidently told single people, especially women, to take charge of their sex lives.

Like all of us, Cosmopolitan magazine’s longtime editor Helen Gurley Brown lived with conflicting drives and desires. But Gurley Brown’s ideas and insecurities had a public platform, where she championed sex for singles while downplaying workplace sexual harassment and featured feminist voices while upholding the beauty ideals that made her own life difficult.

A workhorse who played hard, Gurley Brown, who died in 2012, is presented as an often contradictory heroine and an unexpected success story in journalist Gerri Hirshey’s new 500-page biography, Not Pretty Enough: The Unlikely Triumph of Helen Gurley Brown.

Helen Gurley Brown’s life and example—almost a classic Horatio Alger “rags to riches” tale—affirms that the American idea of surmounting humble origins is sometimes possible, if improbable. But Gurley Brown’s story also illustrates both personal grit and endurance. Wily, willing to take risks, and sexually audacious, she might be a questionable role model for 21st century women, but her amazing story, as told by Hirshey, will nonetheless inspire and entertain.

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Born in 1922, Gurley Brown led Cosmopolitan for 32 years. She moved the magazine, which had been published continuously since 1886, from relative obscurity into the limelight. Known for its brash cover chatter and how-to articles on heterosexual man-pleasing, Cosmo is the world’s highest-selling women’s magazine, with 61 print editions. Its long history—alongside Helen Gurley Brown’s personal story—offers a fascinating window into the intersection between U.S. publishing and burgeoning 20th-century feminist ideologies.

Hirshey (whose earlier books include Nowhere to Run: The Story of Soul Music and We Gotta Get Out of This Place: The True, Tough Story of Women in Rock) presents Gurley Brown as a mess of pushes and pulls: insecure, brilliant, bold, self-effacing, loyal, independent, jittery, and frugal to the point of deprivation. Indeed, Hirshey’s revealing and detailed biography describes the pioneering editor as someone hungry for experiences; a sophisticated New Yorker with deep roots in rural America; and a writer of guidebooks who had trouble taking advice. In short, Helen Gurley Brown was limited by a host of personal issues, but that did not stop her from trying to push societal boundaries and shatter sexual propriety.

A native of small-town Arkansas, Helen’s childhood was marred by tragedy. Her father died in an accident when she was 10; several years later, her older sister, Mary, contracted polio, which left her partially paralyzed. Helen’s mother, Cleo, was overwhelmed and often depressed. Nonetheless, she scrambled to keep the creditors at bay, and the family lived in numerous decrepit rentals during Helen’s childhood.

Poverty was not the only obstacle Helen faced. According to Hirshey, “By the time Mary and Helen were school age, Cleo had begun her steady warnings that pretty girls got the best in life.” While Cleo never used the word “plain” to describe her offspring, it was clear that she did not think them comely. Helen was devastated. What’s more, the fear of being unattractive dogged her for her entire life and she had multiple surgeries to correct “flaws.” She also starved herself and exercised compulsively—and would likely now be labeled as having an eating disorder—to keep her weight at an unwavering 105 pounds.

Her success, Hirshey writes, was the result of luck, tenacity, and sheer chutzpah.

It started in the 1940s, shortly after she finished high school and secured the first of a string of secretarial jobs. During her tenure as a typist and stenographer, Helen cozied up to her male bosses and slept with some of them.

“It was the first time she truly observed and understood that sex is power,” Hirshey writes. “Helen had come to realize that sex was a surprising and thrilling equalizer between the sheets.” Gurley Brown pooh-poohed the idea that people should wait until marriage to have sex and had no problem dating men who were cheating on their wives. The same went, Hirshey writes, for racists and overt anti-Semites. Since she was giving a large part of her earnings to her mother and her sister, it was the size of a man’s bank book, rather than his politics, that evidently curried her favor.

Nevertheless, being a mistress had a downside, and Helen’s diary reveals that she felt like a “little bird … expected to stay in her cage, always available yet always alone.”

Her fortunes turned shortly after her 26th birthday, when she became secretary to Don Belding, chairman of the board at prestigious ad agency Foote, Cone, and Belding. Belding paid Helen $75 a week and treated her like a long-lost daughter; she considered him a surrogate father.

Alice Belding, Don’s wife, took a particular interest in Helen and, after reading something she’d written, persuaded her husband to give Helen a chance as a copywriter. He did, making her one of the first women to break into the field.

Meanwhile, there were men. Lots of men. “Certainly, men love beautiful women,” Hirshey writes. But Helen realized that when “the lights went out, Miss Universe might just as well be the poor, sooty match girl if she couldn’t make him shout hallelujah.” She loved the power sex gave her, but was hurt during a group therapy session when another participant dubbed her a slut. “Spoken with venom, it had the effect of a gut-punch,” Hirshey writes.  Still, it proved clarifying for Helen, allowing her to formulate the idea at the heart of her 1962 book, Sex and the Single Girl: There is nothing shameful about unmarried people having sex as long as it’s consensual.

Helen met David Brown, a high-profile movie executive, in 1958, when she was 36. David was 42, twice married and twice divorced, and had no interest in returning to the altar anytime soon.  This was fine with Helen. Nonetheless, as they spent more and more time together, they formed a strategic partnership. Yes, there was love, but Helen Gurley craved financial security, which David could provide. They wed in September 1959.

At that point, David suggested that Helen take a professional detour and write “a guidebook of sorts for single women.” Hirshey reports that he envisioned “something along the lines of ‘How to Have a Successful Affair’” and ticked off possible subjects, including how to snare a guy and dress for conquest. He also wanted the manual to include concrete sex tips. Helen loved the idea and the pair began to work on it, she as writer, he as editor.

Sex and the Single Girl told the truth as Helen saw it. Hirshey notes that the book was meant as a practicum, “and was never intended as an overtly feminist tract. Systemic change was not at all on her radar; she addressed herself to bettering the small, quotidian lives toiling within the status quo, of those, herself included, she would come to call ‘mouseburgers.’ Sexism was not even in her vocabulary.”

Her message was quite simple: Sex needed to be decoupled from marriage. As for gender roles, she was fine with women playing coy. In fact, she explicitly advised women to go out with men only if they could pay for everything, from dinner and drinks to “prezzies.”

There were of course, detractors, but Sex and the Single Girl sold millions of copies and made Helen Gurley Brown a household name. She appeared on countless TV talk shows and was the first woman featured in Playboy’s famous centerpiece interviews.

In the throes of her success, however, David was offered a job in New York and the couple decided to leave California, where they’d both lived for decades. David, Hirshey reports, knew that Helen needed to work, “that Helen unemployed would be Helen unhinged.” Together, they developed a prototype for a monthly women’s magazine that would popularize and expand upon the ideas in Sex and the Single Girl. They called it Femme and floated the idea to every publisher they knew. No one liked it.

Eventually, Hearst Corporation suggested “superimposing” the format on one of the corporation’s least successful publications, Cosmopolitan, with Helen Gurley Brown at the helm.

It worked, not only boosting sagging sales but catapulting “The Cosmo Girl” to prominence. Sexual freedom, Gurley Brown enthused, was in–but apparently only for heterosexuals, since the magazine rarely acknowledged the existence of same-sex relationships or bisexuality.

Nonetheless, the first few issues tackled then-risqué themes, as these titles suggest: “The Bugaboo of Male Impotence”; “I was a Nude Model (and This is What Happened)”; “Things I’ll Never Do with a Man Again”; “The Astonishingly Frank Diary of an Unfaithful Wife”; and “How to Make a Small Bosom Amount to Something.”

As the “sexual revolution” of the 1960s took hold, Cosmo flourished, albeit steering clear of covering racial unrest, the Vietnam War, or the counterculture and anti-militarism movements. Likewise, if Gurley Brown had any thoughts about the civil rights or peace movements, Hirshey neglects to mention them. She does note that for Helen, “readers of color scarcely registered.” It’s too bad this is not probed more deeply in Not Pretty Enough, and why the editor remained above the fray—was it fear, disinterest, or hostility?—remains unclear.

The women’s movement of the 1960s and 1970s did capture Helen’s interest, though, and she considered herself a devout feminist, with a particular passion for promoting reproductive rights. She wrote numerous articles about the need to overhaul abortion policies pre-Roe v. Wade, openly declaring that “it’s a shame that girls have to go to Mexico or Europe to be operated on.” At Cosmo, she cheered the arrival of the birth control pill in 1960; hailed the 1965 Supreme Court decision in Griswold v. Connecticut that gave married heterosexuals access to birth control; and was exuberant when Eisenstadt v. Baird gave unmarried couples the same right to control their fertility in 1972.

Sexual harassment, on the other hand, was befuddling to her. Remembering her days as a secretary, she dubbed slaps on the ass and sexually suggestive comments to be harmless fun. “When a man finds you sexually attractive, he is paying you a compliment,” she wrote in a monthly Cosmo column. “When he doesn’t, that’s when you have to worry.”

Small wonder that Kate Millett picketed Cosmo for its “reactionary politics” or that Betty Friedan slammed it for its sexism and preponderance of inane articles on keeping men happy.

Despite disagreeing with these thinkers, Helen Gurley Brown marched down New York City’s Fifth Avenue to celebrate the 50th anniversary of women’s suffrage in August 1970 and published articles written by prominent feminists as the 1970s unfolded.

Then, at the height of the AIDS crisis, Gurley Brown stepped in it. In early 1988, Cosmo ran an article that minimized the possibility of heterosexual transmission of HIV and made it sound as if straight women were immune from infection. Equally horrifying, the author, psychiatrist Dr. Robert E. Gould, was overtly racist. “Many men in Africa take their women in a brutal way,” he wrote, “so that some heterosexual activity regarded as normal by them would be close to rape by our standards.”

Oy. Readers were aghast, and Gurley Brown was roundly and deservedly criticized. Even Surgeon General C. Everett Koop weighed in, saying the article did “such a disservice” by suggesting that the risk of contracting the virus was low for heterosexual women. Hirshey reports that, inexplicably, the article was never retracted or corrected.

By this point, however, Helen was showing signs of dementia—she had periodical temper tantrums in public and was becoming less reliable and sharp—so Hearst Corporation brought in several new editors, albeit without firing Helen. She continued going into the office until shortly before her 2012 death. She had done paid work for 71 years.

Hirshey’s sources range from primary documents and in-person interviews with people who knew Gurley Brown, including Gloria Vanderbilt and Barbara Walters. Correspondence and recorded talks between her and friends such as Jacqueline Susann and Joan Rivers provide incisive, funny, and poignant anecdotes. These interviews give the book reportorial gravitas and intimacy. And although Hirshey had only a passing acquaintance with her subject—she had interviewed Gurley Brown decades earlier for an article about marriage proposals—she nonetheless manages to show Gurley Brown as a regular Jane who spoke openly about her nagging doubts.

Many readers will feel as if they can relate to Gurley Brown’s struggles and triumphs. Throughout the book, I felt sad for her, but also wished we’d met.

In fact, I closed the book wanting more; among other things, I wanted to better understand what it was like for her to move between near-poverty and the upper crust. Did she feel like an impostor? Did her lifelong conviction that she was not pretty enough or smart enough keep her from feeling connected to others? Did she ever feel truly secure?

Perhaps Gurley Brown’s self-doubts are what kept her from becoming arrogant or abusive to others; even those who hated Cosmopolitan or were frustrated by her racial and political blind spots admired her kindness. Similarly, these doubts did not prompt her to disguise her eccentricities—among them, pilfering from petty cash and always taking public transportation rather than cabs. Indeed, whatever Gurley Brown felt about her own appeal, Hirshey’s biography presents Helen Gurley Brown the woman as quirky, humble, and utterly fascinating.

Culture & Conversation Media

Behind the Most Creative—and Deserving—Supreme Court Nickname Ever

David S. Cohen

Notorious RBG is a lively, accessible, and smart look at Justice Ruth Bader Ginsburg's life, career, and impact on American law and feminism.

On June 25, 2013, the Supreme Court’s decision in Shelby County v. Holder effectively gutted the Voting Rights Act’s requirement that certain states with racist pasts had to have voting changes “pre-cleared” by the Department of Justice. Basically, Chief Justice Roberts wrote in the opinion, this protection was no longer needed because racism was over.

Justice Ruth Bader Ginsburg’s dissent was furious. She accused the majority of overstepping its authority and ignoring the ways that race discrimination still grips this country, writing, “Throwing out preclearance when it has worked and is continuing to work to stop discriminatory changes is like throwing away your umbrella in a rainstorm because you are not getting wet.”  

When the case came down, Shana Knizhnik, a first-year law student at New York University, was outraged too. Knizhnik almost immediately created a Tumblr as a tribute to Ginsburg, calling it Notorious R.B.G.—a phrase borrowed from a classmate’s Facebook postingin homage to the rapper Notorious B.I.G.—and using Ginsburg’s “umbrella” line as its first post.

From this, an Internet sensation was born. Cities around the country have RBG-inspired cocktails; the Cartoon Network’s show Clarence has a character named after her (Wrath Hover Ginsbot, who is “appointed for life to kick your butt”); babies, kids, and grown-ups (my wife included, just last week) now dress up as RBG for Halloween; she is mentioned in all sorts of popular media, from Scandal to Saturday Night Live; and at least three people across the country have documented RBG tattoos.

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With such a genesis story, you might have expected Notorious RBG: The Life and Times of Ruth Bader Ginsburg, a book inspired by the Tumblr and released from HarperCollins last week, to be a tongue-in-cheek look at RBG in popular culture, with perhaps a few cursory references to her experiences. Even the book design reflects this: Its appearance looks fun and breezy, including the cover image of Justice Ginsburg in a crown, the scribbled case annotations on the inside (one of which, in full disclosure, I contributed), and the many photos and cartoon drawings that break up the prose.

You’d be wrong, though. Instead, Knizhnik teamed up with journalist Irin Carmon to write a lively, accessible, and smart look at RBG’s life, career, and impact on American law and feminism.

It may seem unbelievable that a justice so modest that she once proposed to her colleagues on the D.C. Circuit that they release unanimous opinions without the author’s name on it, so straight-laced that her children once documented every instance of her laughter in their own book called Mommy Laughed, is the now-ubiquitous public figure Notorious RBG. In fact, the moniker itself is an exercise in contrasts. The book notes:

To [Knizhnik], the reference to the 300-pound deceased rapper Notorious B.I.G. was both tongue-in-cheek and admiring. The humor was in the contrasts — the elite court and the streets, white and black, female and male, octogenarian and died too young. The woman who had never much wanted to make a stir and the man who had left his mark. There were similarities too. Brooklyn. Like the swaggering lyricist, this tiny Jewish grandmother who demanded patience as she spoke could also pack a verbal punch.

As Knizhnik and Carmon write, from an early age RBG distinguished herself not only with her unusual intelligence but also with an unrivaled work ethic. She fell in love with her husband at Cornell University because, unlike the other men who “were in awe” of her beauty, he was wowed by her brain and “wooed and won her by convincing her how much he respected her.”

Marty Ginsburg, her husband of 56 years who died in 2010, was a key part of RBG’s life. Though Marty was a highly successful tax lawyer, he happily let his career take a backseat to RBG’s after being made partner at his firm. In fact, when she was appointed to be a judge on the D.C. Circuit Court in 1980, he left his practice in New York to move to Washington and support her career, something unheard of at the time for a husband to do. When there was an opening on the Supreme Court, Marty lobbied everyone he possibly could in Washington to have RBG appointed. She supported him too, helping him through an early bout of testicular cancer while in law school together and raising their young kids while he focused on developing his practice. In the end, though, he wound up happily playing second fiddle to his brilliant jurist wife.

The book chronicles their relationship and love in the context of RBG’s development as a pathmarking (a word she loves) feminist lawyer, and ultimately as the second woman on the Supreme Court. Despite always being the smartest person in the room, RBG faced early pushback while attending Harvard Law School, being told by the dean she was taking the seat of a qualified man. The professors who supported her had to almost beg federal judges to take her for a clerkship, with several openly saying that they wouldn’t hire a woman. And when corporate law firms wouldn’t hire her out of her clerkships, RBG took the advice of a Columbia Law professor who suggested she help him with a book about Swedish civil procedure.

This research changed her life. She traveled to Sweden for the book, where she absorbed the ongoing debates, far advanced from those in the United States in the early 1960s, about women’s role in society. This experience developed her dedication to fighting for women’s liberation’s—as well as for men’s liberation. As the book makes clear, throughout her time as a law professor and at the ACLU Women’s Rights Project, RBG fought for gender equality across the board, believing that the only way women could truly be free was if men also were liberated from the stereotypes of masculinity that bound them.

Many of the cases she took to the Supreme Court reflected this belief—those on behalf of men (like her husband) taking on non-traditional gender roles and the government treating them poorly as a result. RBG was convinced that challenging the sexism behind men’s stereotypes would also free women from the shackles of bigotry as well. Largely because of her dogged pursuit of feminist justice, in a series of cases in the mid-’70s, the Court changed the way it viewed sex discrimination under the Constitution.

RBG was a star litigator who had changed an entire body of law, and she was rewarded by President Carter appointing her to the D.C. Circuit, the federal appeals court in Washington. There, RBG didn’t make many waves, instead hewing closely to Supreme Court precedent and garnering a reputation as a moderate. In fact, based on one study mentioned in Notorious RBG, she voted with Robert Bork 85 percent of the time—yes, that Robert Bork, the uber-conservative, failed Supreme Court nominee who is widely recognized as one of the foremost progenitors of extreme originalism. When Justice Byron White announced his retirement from the Supreme Court in 1993, President Bill Clinton took months before settling on RBG as White’s successor. At the ceremony announcing the nomination, Clinton hailed RBG as a moderate.

Part of this perception came from her longstanding criticism of Roe v. Wade. As much as RBG supported abortion rights and thought them essential to women’s equality, she had written and spoken repeatedly about her belief that Roe was decided too broadly and under the wrong principles. She thought an opinion based on women’s equal citizenship rather than privacy, and which avoided the unnecessary discussion of the trimester framework, would have been more grounded in the Constitution and better for the country as a whole. She didn’t question the importance of abortion for women’s rights or the correctness of the case’s ultimate result in striking down Texas’ prohibition on abortion, but that nuance was lost on the general public. Because she had criticized Roe, she was seen as a Democratic appointment who would not be radical.

Two decades later, with an Internet meme dedicated to her powerful words on behalf of liberal causes, Clinton’s “moderate” appointment seems to have been either a mistake or a clever head-fake. As the book makes clear, RBG has not written many powerful liberal majority opinions in her time on the Court, though her opinion finding that the Virginia Military Institute’s prohibition on women attending the school was unconstitutional sex discrimination acted as a wonderful cap to her past career as a women’s rights constitutional litigator. Beyond that, Notorious RBG doesn’t discuss her important majority decisions around access to the courts for the poor or criminal justice. Overall, however, the Court has been too conservative during her tenure for her to write many other majority opinions in the high-profile cases that have divided it.

Instead, as the book so powerfully details, RBG has found her voice, particularly in the past several years, as the newest Great Dissenter on the Court. A title previously held by Justices John Marshall Harlan, Oliver Wendell Holmes, and Thurgood Marshall, the Great Dissenter speaks in powerful words and is often vindicated by history. That is the position in which we now find RBG. Her pithy and pointed dissents about employment discrimination, voting rights, abortion restrictions, contraceptive access, Medicaid expansion, and affirmative action, all well-chronicled in the book, have garnered her the admiration of millions. No doubt, RBG and her legion of followers hope that history vindicates her as well, and that one day in the near future she’ll be writing majority opinions on those topics.

In light of everything the book covers about RBG’s life—her deceptively frail appearance, her love of opera, her extreme intelligence and bookishness, her lifelong commitment to social justice through law—perhaps the greatest RBG contrast is her enthusiastic acceptance of the Notorious RBG label. In her ninth decade of working harder and being smarter than almost everyone else around her, as Notorious RBG makes clear, it’s not only the most creative Supreme Court nickname ever, but it’s also probably the best-deserved one too.

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