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PARTIAL ANDROGEN INSENSITIVITY SYNDROME (REIFENSTEIN'S

SYNDROME) IN THE ROMAN WORLD

ALAN M. GREAVES

The Classical Quarterly / Volume 62 / Issue 02 / December 2012, pp 888 - 892

DOI: 10.1017/S000983881200047X, Published online: 20 November 2012

Link to this article: http://journals.cambridge.org/abstract_S000983881200047X

How to cite this article:

ALAN M. GREAVES (2012). PARTIAL ANDROGEN INSENSITIVITY SYNDROME
(REIFENSTEIN'S SYNDROME) IN THE ROMAN WORLD. The Classical Quarterly,
62, pp 888-892 doi:10.1017/S000983881200047X

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888 S H O RT E R N O T E S

origin is therefore no likelier for Staberius than any other. Pliny the Elder also
appears not to have known the grammarian’s origin, since he records only that of
his shipmates, Publilius and Manilius, who were Syrians (HN 35.199);15 Suetonius
knew this at least about Publilius, of whom he wrote a lost Life that has been
scantily preserved in a fragment of Jerome (Publilius mimographus natione Syrus
Romae scenam tenet, Chron. Ol. 184.2 = Suet. fr. 26 Reiff.). Suetonius does not
seem to have had any such information on Staberius.

New York T R I S TA N P O W E R
tristan.power@gmail.com
doi:10.1017/S0009838812000468

whose origins are not explicitly stated, but may be suggested already by their names: Aurelius
Opillus (Gram. 6.1), Cornelius Epicadus (12.1), Plotius Gallus (26.1) and Otacilius Pitholaus
(27.1–2), with Kaster (n. 1), 111–12, 162, 292 and 299 respectively.
15 
Baldwin (n. 13), 433–4 argued for the dependence of Gram. 13.1 on Plin. HN 35.199–200,
but a common source may be more probable; see Kaster (n. 1), 344–5. On the interpretation of
Pliny’s passage, which does not imply that Staberius too was Syrian, see ibid. 167; cf. above,
n. 3.

PARTIAL ANDROGEN INSENSITIVITY

SYNDROME (REIFENSTEIN’S SYNDROME) IN
THE ROMAN WORLD

Partial Androgen Insensitivity Syndrome (PAIS) is a rare endocrine dysfunction

affecting male children, and has had numerous different appellations, the most
commonly known being Reifenstein’s Syndrome. In cases of PAIS male children are
born with defects in the amino-acid structure of the androgen receptor. Androgens,
such as testosterone, are the male hormones that are responsible for the develop‑
ment of male sexual characteristics in the developing child. Androgens are produced
and released into the blood stream as normal in cases of PAIS, but they have no
effect on the child’s development. Male humans produce both male and female
hormones and production of both increases greatly during puberty. Where the male
hormone receptor is defective, as in PAIS, only the female hormones take effect
and feminization occurs with the onset of puberty.1

1 
G.M. Besser and M.O. Thorner, Clinical Endocrinology (London, 19942), 11.13–18; L.J.
De Groot (ed.), Endocrinology (Philadelphia, 19953), 2239–40; A. Levy and S.L. Lightman,
Endocrinology (Oxford, 1997), 213–20; J.A.H. Wass and S.M. Shulet, Oxford Textbook of
Endocrinology and Diabetes (Oxford, 2002), 978–9; P.R. Larson, H.M. Kronenberg, S. Melmet
and K.S. Polansky, Williams Textbook of Endocrinology (Philadelphia, PA, 200811), 672; R.
Werner ‘46,XY disorders of sex development – the undermasculinised male with disorders of
androgen action’, Best Practice and Research Clinical Endocrinology and Metabolism 24 (2010),
263–77, at 265–6.
 S H O RT E R N O T E S 889

In effect, babies with PAIS are born genetically and physically male, with
predominantly male external genitalia until puberty when, with the increase in
female hormones, they develop the secondary sexual characteristics of females.
These include gynaecomastia (the growth of breasts), lack of facial hair and no
deepening of the voice. The result is called pseudohermaphroditism, as the child is
genetically male and displays only the secondary sexual characteristics of a female,
as opposed to the much rarer condition of ‘true’ hermaphoditism in which both
sets of genitalia are present.2 The condition is a spectrum disorder and it affects
different individuals to a different degree, from there being little noticeable effect
to near-complete feminization. These various states were once considered to be
different conditions, but are all now recognized as degrees of manifestation of the
same syndrome, namely androgen insensitivity.
Reifenstein’s Syndrome is a genetic condition that has no known environmental
cause, so in order to understand its origins in the history of the human genome it is
useful to consider when and where it has affected the human population throughout
time. Without medical autopsy it is hard to show conclusively that cases of the
condition existed in the ancient past, but there are references in Roman literature
that can be interpreted to suggest that the condition may have existed in Italy as
far back as the last few centuries of the first millennium b.c.
Julius Obsequens’ Prodigiorum liber records bizarre portents and paranormal
phenomena, such as lightning strikes on temples and showers of blood falling from
the sky, and was probably compiled from prodigy lists in the fourth century a.d.3
Amongst them Obsequens records the birth of a number of babies of indeterminate
gender in the second and early first centuries b.c.4 From Livy we know that the
birth of a ‘hermaphrodite’ baby was considered to be a supernatural phenomenon
that was considered to be a portent of divine displeasure that should be expiated
by ritual observances such as sacrifice, prayers and ceremonies.5 In accordance with
the laws at the time, such babies were killed by drowning or exposure, which
would in turn be followed by further ceremonies.6
In addition to the birth of babies of indeterminate gender, Obsequens also men‑
tions three older children who were found to be hermaphrodites and were similarly
taken out to sea and drowned. These included a child of eight from Rome,7 a child

2 
W.A. van Niekirk, True Hermaphroditism: Clinical, Morphological and Cytogenic Aspects
(New York and London, 1974); S.J. Kessler, ‘The medical construction of gender: the case
management of intersexed infants’, Signs: Journal of Women in Culture and Society 16 (1990),
3–26, at 5.
3 
B. McBain, Prodigy and Expiation: A Study in Religion and Politics in Republican Rome
(Brussels, 1982), 127–35.
4 
Obsequens records that infants were identified as hermaphrodites at Luna in 142 b.c.
(Prodigiorum liber 22), in Ferentine territory in 133 b.c. (ibid. 27a); in Forum Vessanum in
122 b.c. (ibid. 32); in Rome in 98 b.c. (ibid. 47); and in Urbinum in 95 b.c. (ibid. 50). He also
records a boy born with two sets of genitalia in 136 b.c. (ibid. 25) and a woman with double
genitalia was found in 92 b.c. (ibid. 53).
5 
Livy 27.11.1–6; 27.37.4–15; 31.12.5–10; 39.22.2–5. D.S. Levene, Religion in Livy (Leiden,
1993), 2–6, 65–6.
6 
See Levene (n. 5), 79–80, discussing Livy 31.12; R. Garland, The Eye of the Beholder:
Deformity and Disability in the Graeco-Roman World (London, 1995), 16–18; Dion. Hal. 2.15.1–
2; Livy 27.37.6; Julius Obsequens, Prodigiorum liber 22, 27a, 32, 47 and 50.
7 
Prodigiorum liber 34.
890 S H O RT E R N O T E S

of ten from Saturnia8 and a child of twelve from Umbria.9 Livy also mentions a
further incidence of a child aged sixteen, who lived among the Sabines but whose
sex could not be determined.10
Roman society imposed clearly differentiated roles on males and females and
great value was placed on the production of male heirs.11 There were also very
strict and clear procedures for disposing of ‘hermaphrodite’ babies. Given this
context, it is remarkable that the four older children mentioned by Obsequens and
Livy had ever been allowed to live beyond infancy. However, their age range (8
to 16 years) is consistent with the late onset of the outward signs of feminization
typical of PAIS, at the age when puberty takes place.12 It is therefore possible to
suggest that these children may have been experiencing PAIS and had been born
with external male genitalia and were being raised as males until feminization had
occurred in puberty as a result of their unseen genetic disorder.
It should be noted that other interpretations are possible, such as Leydig Cell
Tumour cancer, a form of testicular tumour that produces oestrogen and can result
in gynaecomastia. However, this form of cancer is rare (one to three per cent
of all testicular neoplasms) and is more common in older men (median age 60
years).13 The age of the children in question therefore points towards a more
probable connection with puberty. Another possibility is that, being mindful of the
laws that dictated the killing of such children at birth, the parents of babies of
indeterminate gender may have concealed their condition from the outside world,
only to be found out at a later date.14 In such an instance no feminization would
need to have occurred as the child may have exhibited both sets of genitalia since
birth.
If indeed feminization had occurred, then it is useful to consider these passages
within the broader context of Roman discourses about virilization.15 This was a
subject in which there was evidently much interest, judging by the attention given
to the rare number of reported cases of female to male virilization.16 This interest
may be moral or salacious, as in the story of the wife who became a man while
her husband was away, causing complications in the marital bed on his return, or
the priestess of Demeter, who was subsequently tried ‘for having witnessed what
was not to be seen by a man’.17 However, the interest may be more intellectual,
as it reflects contemporary conceptions of the male and female bodies.18 As with
our proposed cases of feminization, the reality and specific nature of these cases
of virilization is difficult to determine with any degree of certainty, but such

8 
ibid. 36.
9 
ibid. 3.
10 
Livy 31.12.6.
11 
M.W. Gleason, Making Men: Sophists and Self-presentation in Ancient Rome (Princeton,
1995).
12 
Levy and Lightman (n. 1), 213–20; Besser and Thorner (n. 1), 13.2–26.
13 
R. Amato, ‘Testicular cancer’, in J.R. Bertino (ed.), Encyclopedia of Cancer (San Diego,
CA, 2002), 363–75, at 366.
14 
Garland (n. 6), 16–18.
15 
M. Beagon, The Elder Pliny on the Human Animal (Oxford, 2005), 173–5.
16 
Livy 24.10; Pliny HN 7.36; Phlegon of Tralles (FGrH 257 F 36.6).
17 
Garland (n. 6), 128–32, citing Diodorus 32.10.2–9 and 32.11.
18 
T. Laqueur, Making Sex: Body and Gender from the Greeks to Freud. (Cambridge, MA,
1990), 149–92; R. Flemming, Medicine and the Making of Roman Women (Oxford, 2000),
114–22.
 S H O RT E R N O T E S 891

accounts do appear to accord with the medico-biological theories of Galen19 that

regard female genitalia as an inverted and internalized version of the male, which
might become  externalized through excessive body heat.
If the interpretation of feminization offered here is accepted, then it would con‑
firm that PAIS has been present in the human population of the Italian peninsula
for over two millennia and this may contribute towards understanding the genetic
origins and history of this condition. It is interesting to note that there is a similar
condition that can result in virilization of previously female children during puberty
– 5-Alpha Reductase Deficiency Syndrome (5-ARD).20 Whereas 5-ARD occurs in
geographically discrete populations in the Dominican Republic and New Guinea,21
often with a familial connection, PAIS can be seen in populations across the globe
and appears to affect the general population in very low numbers, a pattern of
epidemiology that this new interpretation would suggest is a long-established one.
The consequences of this late onset of feminization, if that is indeed what it
was, were tragic for the four individuals mentioned because of the strict legal,
social and religious practices of the time. However, different societies hold differ‑
ent opinions about how gender is defined and the place of hermaphrodites in their
society.22 The past was not homogeneous, nor was it achronological and attitudes
to hermaphrodites can be expected to have varied between the different regions
of the ancient world, and over time. As an example of the regional differences in
attitudes towards hermaphrodites, it is useful to note Mary Beagon’s comment that
‘Rome’s destruction of hermaphrodites ironically coincided with their popularity
in Hellenistic art’.23 In such art, Hermaphrodite was respected as a divinity and
is frequently depicted in sculpture with male genitalia and breasts.24 Such images
may have been modelled on individuals who experienced PAIS because ‘true’
hermaphroditism, in which both male and female genitalia are present, is so rare.25
As an example of how attitudes changed over time, it is worth considering the
Roman philosopher Favorinus who claimed to have changed sex during his lifetime,
possibly as a result of Reifenstein’s Syndrome.26 It was possible for Favorinus to
survive to adulthood because in the era in which he lived (second century a.d.)
Roman society’s attitudes towards hermaphrodites had changed to become more
accepting.27
In the modern world, there is currently no cure for this genetic condition but,
thankfully, the attitudes of contemporary societies are generally more favourable
towards those who experience PAIS than was the case in ancient times. Because
PAIS is a spectrum disorder, treatments will vary from individual to individual,

19 
Gal. De usu partium 11.297; Beagon (n. 15), 175–6.
20 
Beagon (n. 15), 173–4.
21 
G. Herdt, ‘Mistaken sex: culture, biology and the third sex in New Guinea’, in G. Herdt
(ed.), Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History (New York,
1994), 419–45.
22 
T. Ingold (ed.), Companion Encyclopedia of Anthropology (London and New York, 1994),
813–21; C. Geertz, Local Knowledge (London, 1983), 80–5; L. Brisson, Le sexe incertain:
androgynie et hermaphrodisme dans l’Antiquité gréco-romaine (Paris, 1997), 129–31.
23 
Beagon (n. 15), 167, discussing Pliny HN 7. 34.
24 
R.R.R. Smith, Hellenistic Sculpture (London, 1991), 133–4.
25 
R.L. Summit, ‘Differential diagnosis of genital ambiguity in the newborn’, Clinical
Obstetrics and Gynaecology 15 (1972), 112–40; van Niekirk (n. 2), 83.
26 
S. Swain, ‘Favorinus and Hadrian’, ZPE 79 (1989), 150–8, at 154 esp. n. 14, citing Philostr.
VS 489 and Polemon, Physiognomica 1.161 F./H.
27 
Pliny HN 7.34. See also Beagon (n. 15), 166–9.
892 S H O RT E R N O T E S

depending on the degree of genital ambiguity and the type of androgen receptor
mutation present. In some cases it is possible to use large doses of androgens to
stimulate sexual development.28 Where this is not possible, contemporary treatment
practice recommends that the child be reared as the sex most appropriate to the
degree of genital and physical abnormality displayed, usually the female.29 Clinical
practice used to suggest that it was often best for the child’s long-term develop‑
ment to have plastic surgery and be raised as a female,30 but such decisions often
assumed a simplistic diametric male/female definition of gender.31 Modern practice
now recognizes the wide range of variations that are possible within the PAIS
spectrum and individualized treatment plans are recommended.32 With counselling
for both the child and the parents and possible hormonal and surgical interventions
it is today possible to give those affected an awareness of the syndrome and help
them to make decisions that will contribute to their living healthy lives with their
condition.33

University of Liverpool A L A N M . G R E AV E S
greaves@liv.ac.uk
doi:10.1017/S000983881200047X

28 
W. Weidemann et al., ‘Response to androgen treatment in a patient with partial androgen
insensitivity and a mutation in the deoxyribonucleic acid-binding domain of the androgen recep‑
tor’, Journal of Clinical Endocrinology and Metabolism 83 (1998), 1173–5.
29 
Wass and Shalet (n. 1), 978–9.
30 
Summit (n. 25); C.W. Bardin, Current Therapy in Endocrinology and Metabolism (St Louis,
MO, 19976), 380–3.
31 
Kessler (n. 2); R. Sorenson, ‘Borderline hermaphrodites: higher-order vagueness by exam‑
ple’, Mind 197 (2010), 393–407, at 397.
32 
C.E. Brain et al., ‘Holistic management of DSD’, Best Practice and Research Clinical
Endocrinology and Metabolism 24 (2010), 335–54; P.T. Cohen-Kettenis ‘Psychosocial and psy‑
chosexual aspects of disorders of sex development’, ibid. 325–334; S.F. Ahmed and M. Rodie,
‘Investigation and initial management of ambiguous genitalia’, ibid. 197–218; I. Vidal et al.,
‘Surgical options in disorders of sex development (dsd) with ambiguous genitalia’, ibid. 311–24.
33 
In some circumstances, for example, there is an increased risk of certain types of testicu‑
lar cancer and a prophylactic gonadectomy may need to be considered. See L.H.J. Looijenga,
‘Gonadal tumours and DSD’, Best Practice and Research Clinical Endocrinology and Metabolism
24 (2010), 291–310.

LIBANIUS THE FLATTERER

Eunapius of Sardis’ Lives of Philosophers and Sophists includes a biography of

the deceased Libanius.1 In the course of it, he provides a character sketch of the

1 
Discussed at some length in R.J. Penella, Greek Philosophers and Sophists in the Fourth
Century a.d.: Studies in Eunapius of Sardis, ARCA: Classical and Medieval Texts, Papers and
Monographs 28 (Leeds, 1990), 100–7, and more recently in S. Swain, ‘Sophists and emper‑
ors: the case of Libanius’, in id. and M. Edwards (edd.), Approaching Late Antiquity: the
Transformation from Early to Late Empire (Oxford, 2004), 373–9.