Being Human in a Buddhist World: An Intellectual History of Medicine in Early Modern Tibet

Gender and the status of women are complicated matters to take up in any context. Inevitably they entail contested issues in which not only the objects of our study but also we, the researcher or student, have personal stakes. Stakes can cloud our perceptions. Add to this the nature of gender itself—by which I mean the style and significance associated with sexual identity.¹ Such associations are often vague or inconsistent, if articulated at all.

The present chapter comes firstly out of a curiosity on my part. Should we expect the physician’s immersion in medical realities to make a dent in the recalcitrant prejudices about women otherwise at work in a given cultural milieu? Does the putative focus on physical facts lessen the likelihood that medical theorists will participate in gender stereotyping? Anyone who has ever engaged in gender studies will readily anticipate the answer: mixed at best. For its part, Tibetan medical writing produces starkly misogynist passages on occasion. But there are also a few surprising moments when certain theorists soared above the usual consignment of the female to inferiority and even made liberative suggestions about gender. In addition to exploring how and when that happened in medicine, I also wonder how it compares to instances in Buddhist history where gender prejudice was addressed. I will only be able to gesture in such a comparative direction in the conclusion to this chapter. But I hope at least to lay the groundwork, from the medical side, for future exploration of the question.

Gender conception in any event parallels larger themes of this book. Gender as a category has everything to do with the relation between material existence and representation—the connection and yet also distinction between the physical body and its socially legible markers. As for other issues we have examined, powerful assumptions coming from Buddhist epistemology, ritual, ethics, and soteriology are well nigh naturalized for Tibetan medical writers on gender too. And yet considerations distinctive to the clinic sometimes conspired to trouble such naturalizations, at least by the early modern period. By the end of this chapter we will find Zurkharwa Lodrö Gyelpo once again trying to separate conceptual categories from the reality that they would represent, aware of the illusions into which such categories seduce us at the expense of accurate knowledge of individual particularities. He even develops a term to name the fact that real human beings do not necessarily display the qualities that their sexual identity would suggest. As he makes very clear, gender is but a designation, and is distinct from anatomy.

Finally, the material in this chapter provides a chance to track how Tibetan medicine received and responded to other Asian medical traditions with some specificity. Unlike the topics of the previous chapters, which were unique to debates initiated in Tibet and thus suggest only the broadest grounds for comparison (on the order, for example, of asking why Indian medicine didn’t produce medical texts preached by deities, or invoke clinical experience to question yogic anatomies), the Four Treatises’ handling of women’s medicine shows close debts to Ayurveda, reproducing certain passages almost verbatim. But this allows us to notice what is nonetheless different in the Four Treatises and to ask why. Some of those differences have to do with Tibetan kinship patterns. There are also places where disparate medical streams have had some influence, such as in the introduction to an otherwise Ayurvedic passage of the gonadlike samse’u that is probably indebted to East Asian medicine; or the appearance in the Four Treatises of a uniquely gendered version of the Chinese diagnostic pulse tradition; or the occasional listing of blood as a fourth humor, which probably has a western Asian pedigree, and so on.

In looking for what is distinctive and historically specific, however, we should avoid any easy assumption that the parts of women’s medicine in the Four Treatises that are influenced by medical streams from afar are for that reason not “Tibetan.” In adopting and adapting Indic and other imported medical concepts throughout the Four Treatises—and Yutok selected and restated such material judiciously—the Tibetan doctors were making it their own.2 The knowledge so deployed worked for them, and it accorded with what they already knew or suspected about the human body. Those occasions where Tibetan medical writers found the need to challenge what they were inheriting were rarely about foreignness per se (the Buddha Word debate does indeed raise issues about Tibetanness, but in service of a very different question).³ Although the Fifth Dalai Lama and his court were aware of the value of searching abroad for new information and therapies, Tibetan medical tradition does not systematically distinguish foreign medicine from Tibetan medicine in just those terms. In short, our concern to discover innovation has to do with the conditions under which change occurs, not the cultural or national identity of those shifts as such.

With these several aims in view, the early materials we will look at, along with a few later interventions by Tashi Pelzang, Kyempa, and Zurkharwa, provide cause for both marvel and dismay. The following must nonetheless be limited in what it considers. Notions of gender and issues about the anomalous nature of women’s bodies abound in Tibetan medical theory and practice. I will only take up a few interesting high points and some rather challenging low points—from a feminist perspective, that is—so as to puzzle over how to account for both.

I will not in any case be able to recover much of women’s voices in all of this. Reports on experience by women surely fed Tibetan academic medical writing, but this is recognizable only through a close feminist reading, and only in the barest echo. What we see instead are (male) medical writers grappling with issues of sex and gender in ways that sometimes show their cognizance of women’s experience. And that is not to mention a quite surprising insistence that it is important to account for women’s bodies on their own terms. I will start with this encouraging, if rather puzzling, development first.

The Four Treatises diverges significantly from Ayurveda in at least one fundamental respect. It counts the illnesses specific to females as one of its eight principal “branches,”4 respecting a long-standing Ayurvedic tradition that there are eight main branches, or sections, of medical knowledge. But it offers a different conception of what those eight sections are. In Ayurveda, obstetrics and embryology were part of the pediatric section of medical knowledge. Female medicine as such did not constitute its own branch. Aṣṭāṅgahṛdaya lists the eight branches as body (i.e., general internal medicine); pediatrics; demon possession; upper body; surgery; poison; geriatrics; and virility and fertility.⁵

The author(s) of the Four Treatises, in contrast, found it necessary to conceive of female pathology as its own branch.⁶ They substituted it for Ayurveda’s “upper body,” which focuses on eye, ear, nose, and throat. In the Four Treatises system, that branch is incorporated into the more general “body branch.” Thus the Four Treatises lists its eight sections as body; pediatrics; female pathology; demon possession; wounds and surgery; poison; geriatrics; and virility/fertility.⁷

Why the switch? And what did it accomplish?

The answers are not entirely clear. Some aspects of the rationale appear to be missing from the record. Still, we can tell a lot from what we do have. At least two early works provide sustained discussion of the assumptions behind the branches of medical science.⁸ Ostensibly concerned with the more general question of why there are only eight branches (not more, not less), these pages show a recurring concern about the rationale for a female pathology branch.

It is especially striking to see the defiant response to the criticism that the shift deviates from Ayurvedic tradition and the Aṣṭāṅgahṛdaya:

While in the Aṣṭāṅgahṛdaya an upper body branch is expounded, here in the Four Treatises a female pathology branch is expounded. If one were to argue that this contradicts the norm in medical science,9 then the answer is: This so-called contradiction of the norm, is it that this Four Treatises is in contradiction to the norm, or is the contradiction of the norm in the normativity of there being eight branches, or is it that since eight branches are the norm it contradicts [other] normative treatises? A definitive argument has not been established. Since this Four Treatises is spoken by the Buddha Bhaiṣajyaguru, the four medical traditions are incidental. Thus a definitive statement on what are the normative eight branches has not been established. [Your wrong conclusion is based on assuming] that the sages’ explanation is the most important one.¹⁰

In this clever and yet evasive rejoinder, the defense simultaneously contests that there is a single norm in medicine at all, and pulls out a trump card—just in case there is such a norm. It challenges the idea that the “sages’ explanation,” i.e., Ayurvedic tradition, is the most authoritative source of medical knowledge. Instead it not only invokes the heterogeneous genealogy for medical knowledge, referring to the four medical traditions, i.e., as represented in the Four Treatises’ fourfold audience of gods, sages, tīrthikas, and Buddhists, but also goes on to trade on the Four Treatises’ status as Buddha Word in order to relativize all of them. Indeed, here that status served medicine well, providing the rhetorical tools to proceed with what was thought to be a better way to organize knowledge. Thus do these defenders of the Four Treatises escape any pressure to conform to what in other contexts would constitute authoritative medical tradition, by virtue of the conversation-stopper that the Four Treatises—and its counting of female illness as one of the eight branches—is the Word of the Buddha. End of discussion.

Our two early sources nonetheless do go through a number of arguments, beyond this display of bravado. Still, they don’t offer much reason for the shift other than a simple conviction—but perhaps this is a lot—that female illness is unique and needs to be treated on its own terms.

The discussion is notable for its overt acknowledgment of the androcentrism of received medical tradition. On several occasions the lynchpin is that the general “body branch”—which in the Four Treatises is said to consist of seventy chapters, far more than any of the other branches, and covering most workings of the human body—renders the body of the adult man as “primary.”11 Although the discussion grants that many features of the body are common to all people (such as general aspects of illness, vital fluids/bodily constituents, and imbalances¹²), the androcentrism of the body branch nonetheless becomes the main reason another special branch is not needed for the adult man, while it is needed for the female, the elderly, and children.¹³

Even though the (adult man’s) body branch is understood to be basic to all the other branches, a key metaphor illustrates that the medical specialties those represent are also necessary. One passage analogizes the various branches of medical science to a situation wherein a father appoints his son to control eight communities of people. When this is seen to be too difficult, that son (i.e., the body branch of medicine) in turn sires seven sons of his own (the other seven branches) to complete the task. Such specialization is required in medicine since what is taught about the body in general does not suffice for all medical contexts, especially those illnesses particular to children, women, the aged, and with respect to sexual performance.¹⁴ A second analogy regards “the eight major activities of human life,” interesting in its own right for what it says about Tibetan society around the time and place of the Four Treatises’ composition. These are agriculture; animal husbandry; explaining the Dharma; medicine; calculation; performing rites of aid; building and crafts; and making temples.¹⁵ Here too the point seems to be that such activities are not reducible to each other and therefore require specialized expert knowledge.

Another pertinent discussion that turns on how much males and females have in common or not concerns whether the virility branch of medicine bears upon women. Here again is an admission that the concerns in this branch are androcentric. Yet since in the end, what are important are reproduction and especially the reproductive fluids, it is maintained that the virility branch pertains to both male and female. Both male and female sexual fluids ultimately have their source in the gonadlike samse’u organ in the body, these commentaries assert, and both males and females care about having children (or sons).¹⁶

Although this point might be read as a reason a special female branch is in fact not needed, it is used instead to make the opposite argument, i.e., that while most of the Four Treatises refers to humans in general, some issues, such as specifically female pathologies, still need specifically focused discussion. For example, one passage asks whether treatment for pathologies of the uterus should be considered part of the general body branch.17 The critic argues that if indeed the body branch ignores female pathologies, then it is really but “half a branch.” While this recognition that female bodies and their diseases should be as important as male diseases—and females make up half of the human population—is laudable, in rejecting its logic, the defenders of the Four Treatises are making a more basic assumption that, again, there needs to be a separate specialization in female pathology.

Since the text of the Aṣṭāṅgahṛdaya does not include a branch to heal female pathologies, there is the upshot that its branches are incomplete. If you say it does have the healing of female illness, then is that contained in [its own] branch or is it contained by being subsumed into the body branch? If it is contained by being subsumed into the body branch then that goes against the explanation of healing twenty kinds of uterus disease in the Final Treatise. If it is not subsumed in the body healing branch, then it violates the premise that it is in the body. And yet [if it is in the body branch] there would be the problem that not all [uterus] diseases would be female illnesses.¹⁸

The passage is recondite in its language. It ponders how to best remedy a problem in the Aṣṭāṅgahṛdaya’s assumptions. Should female maladies be subsumed into the general body branch? If they are, then what about the specialized information provided in the Final Treatise on particular female diseases?¹⁹ Further, if uterus problems were not put in a special section for women’s illness, it would imply that they were not necessarily a female issue. In other words, all female illnesses should be in a special section, since female illnesses are not common to all bodies. And yet there is another category problem in tension with this point. If the female illness branch is not put in the body branch, then the very premises of the body category are violated, because this could suggest that female illnesses are not a human condition—a double bind also recognized by modern feminists.

Such a point is brought home further in another passage on whether it would be possible to reduce the number of branches to seven by leaving out female pathology as a branch altogether. Since male and female bodies are taught similarly, why the need for a branch exclusively on the female body? Moreover, would it not be but a half-branch (i.e., since all other branches relate to both sexes)? But the response is instructive. If a branch is organized around medical specialty with regard to the object to be treated, then such a specialized branch cannot be said to be incomplete or missing the other half of humanity, since it was already defined in terms of that specialization. If you had some sons and assigned two estates to each, but to one of them you gave only one, you would not say that was half an estate.20 The example reiterates that it is legitimate to have a branch that is sex-specific. But note that this right seems to be granted only for females. Perhaps the largesse makes up somehow for the androcentrism of the main body branch.

Several other passages also insist that while the general body section is gender inclusive, specialized sections on certain topics, of which female pathology is most exemplary, are needed and justified. In contrast, there is no justification for a branch devoted to the upper body alone, such as the Aṣṭāṅgahṛdaya suggests.²¹

In any event, whatever principle is being articulated is not fully achieved in practice. In the actual organization of the Four Treatises, the female pathology branch is identified as chapters 74 through 76 in the Instructional Treatise. But information on female medicine is not confined to this section. There is also female-specific information in what is ostensibly the body branch: on conception, pregnancy, and menstruation in the embryology chapter; on conditions of the uterus, vagina, and menstrual irregularities in the virility and fertility chapters. Next to a chapter on the male genitals, there is also a separate female genitals chapter (which mostly repeats the content of the female branch chapters in briefer form).

The overlap and disorganization may indicate that the female branch chapters were added later as an afterthought, gathering together female-specific material from throughout the Four Treatises without adjusting the rest of the work accordingly.22 Or it may just be one more sign of the general disorganization of the Four Treatises, whereby anatomy, physiology, and other topics are to be found in several different sections. And it is certainly not the case that all of the material in the body branch chapters is applicable to both sexes. Not only is there the female-specific material, as just noted, there is also the chapter on the male genitals that touches on penis malfunctions, as well as chapter 68 of the Instructional Treatise, which concerns the testicles.

Medical information on female conditions in particular was also disorganized in Ayurvedic texts. Martha Ann Selby writes that she has “gained no real sense of a coherent idea of gynecology in the Greco-Roman sense, or in the contemporary Western sense, but this has much more to do with the ways in which disorders and their treatments are taxonomically understood and arranged, rather than with a lack of information. … But for whatever reason, it remains true that the bodies of women seem somehow fragmented and dispersed across the wholes that are these two texts.”²³ In fact, at least in the case of Aṣṭāṅgahṛdaya, the difference between its organization and that of the Four Treatises’ presentation of women’s medicine is slight. In the former, most of the information covered in what the Four Treatises calls its female pathology section is gathered in the first two chapters of the Śārīrasthāna. This suggests that the innovation that the early Four Treatises exegetes were touting may have been more about self-presentation and nomenclature than anything else.

Writing several hundred years later, Zurkharwa Lodrö Gyelpo comments pertinently on the wisdom of creating a female pathology branch of medicine and helps guide our own understanding. He cites a variety of criticisms of the Four Treatises’ branch system, including one disputing the very idea of special branches, saying they should all just belong to the main body branch.²⁴ Zurkharwa incisively points to the confusion around the word “body” in the term “body branch.” Does it refer to that which is basic to all medical issues, or to a branch that should be distinguished from the other branches? Does the latter option make the other branches thereby not part of the body?

Once again Zurkharwa wants to talk about “context.”25 The word “body” is used in different ways in different contexts. “Bodily illness,” which names the subject of all the various illnesses for people “with bodies,” is “just a designation; it is not the body as such.” Adding that there is no need to articulate a category such as “illness of the adult” when what is discussed there is common to all illnesses of adults, Zurkharwa evinces again a probative attitude to language and the difference between heuristic categories and the reality that they would denote. He notes how the eight branches are construed differently by various sources, such as Suvarṇaprabhāsottama, as well as in varying contexts in the Four Treatises itself. These points serve the very important function of carving out freedom for medical scholarship: to reconsider categories, to organize them in ways that make sense, and to shift that organization when needed. This is not to say Zurkharwa does not betray his own unexamined assumptions about categories. When he argues that there is no male pathology that is parallel to the kinds of illnesses under the heading of female pathology, but makes no similar point the other way around, he seems to think that there is something intrinsically female about female pathology that has no analog in male illness. In this he seems to imply that male medicine can represent issues common to both males and females, while female medicine cannot.

But rather than getting sidetracked with Zurkharwa’s own androcentrism, my point is simply to note how determined the medical scholars were to have a section of medical knowledge specific to females, even at the cost of reason. When Zurkharwa concludes his discussion with an insistence that this whole debate is meaningless since it is based on confusion about what the term “bodily illness” denotes, it reinforces how arbitrary the entire argument is.

And that only begs the question of why the Tibetan doctors insisted on this shift from classical Ayurveda in the first place. We might be tempted to read some proto-feminist motivation in it, to see it as a clear-eyed recognition that making the male normative for medical knowledge can be a costly error, as has been recognized in recent feminist history of science.26 And yet the implications of having a special section on the female and not one for the male are multiple and potentially at odds. On the one hand it is understandable to want to isolate obstetrics as its own specialty, given the special role that the mother has in producing offspring, in turn so central to human flourishing. And yet on the other hand—and this again has been massively recognized in feminist thought—claims to uniqueness are a double-edged sword. They can correct a previous imbalance in the opposite direction, such as the androcentric bias seen in the Four Treatises. But they can also serve to limit gender flexibility, to inscribe gender essentialisms, and to underscore male privilege. Joan Scott puts the problem well: “women are either the same as men (but better represented by men) or they are too different to be taken into account. These contradictory assumptions have both resulted in the exclusion of women—from clinical trials and from a range of other things.”²⁷

It may well be that the resistance to isolating male pathology in its own section had to do with a worry that this would remove the male from his pride of place as the default normative body. Indeed, despite the notable self-awareness of medicine’s androcentrism that we have just seen, the very visibly sexed renderings of medical knowledge in the Desi’s seventeenth-century painting set still make that androcentrism, and especially the answer to the question of which sex can represent gender-neutral conditions (answer: the male), patently clear.²⁸

Neither the lack of clarity about why this category shift was needed nor the inconsistency with which it was implemented undermines its significance. Quite the contrary, the shift’s ultimately arbitrary nature makes it all the more telling. What remains when consistency and function fall away is rhetoric. Something—or perhaps several things—was gained by creating a branch of medicine devoted to females. It is possible that one of those things was to display a concern for scientific accuracy. But the shift might also have served to balance out the implications of another rhetorical agenda in the Four Treatises, which is nowhere more evident, ironically, than in the opening lines of the chapters that actually make up the touted female branch. As far as I know, the passage is unique to the Four Treatises. It seems to reflect a particular set of concerns of its author and his milieu.

The introduction to the first of the three female pathology branch chapters is stridently polemical. This is already evident in the way that the statement stands back to offer a general assessment of the female condition, in broad strokes and in terms that quite exceed the medical. Whatever good news there might have been in the recognition of a separate women’s medicine is taken away in these opening lines. The statement trades heavily on the reigning Buddhist misogyny: to be born a female is the result of bad previous karma, excess desire, and a low store of merit.

The statement makes various claims about female physiology. But seemingly gratuitous to the medical overview, the passage’s misogyny could not be more overt. The female state that the ensuing chapters will address is the result of a low store of merit. It really looks like a deliberate chastening. Yes, we are going to take a special look at female medicine, but let us remind you at the outset that if there is anything special about being female, it is that it is a special misfortune.

Note that low merit, a classical Buddhist notion, has the medical upshot that the body is marked by the three “special extras” of the female: breasts, uterus, and the monthly cycle. This language bespeaks of course a fundamental androcentrism already evident in early Ayurvedic accounts of human anatomy, albeit without the misogynistic valence added by the Four Treatises. But in all such cases, the features that distinguish a person as female are something extra on top of the norm.33 Elsewhere in the Four Treatises is further indication of the female’s aberrational status: her extra fluids in the body, her extra flesh, her extra orifices (see figures 6.2 and 6.3).³⁴ Never is it thought to count the male’s penis and scrotum as extras—as indeed they might be, if the perspective of Tibetan medicine were instead gynocentric.

It is not clear if we should recognize as a further medical misogyny the count of specifically female illnesses as forty. In contrast, the specifically male diseases are usually counted as seventeen.³⁵ Perhaps the discrepancy represents a genuine recognition of a greater number of ailments in women.³⁶ But the passage turns her elevated vulnerability to sickness into an affront: “Since she is a low birth the woman’s body has extra [illnesses].”

Actually Kyempa provides some corrective when later on he notes a count of special illnesses for both men and women.³⁷ The early modern commentators also seem to show some discomfort with the Four Treatises’ outright misogyny. In commenting on the introductory passage to the female pathology section, Kyempa, followed closely by Darmo and the Desi in the following century, provides two alternate views of the female gender. One concerns certain bodhisattvas who manifest as females and spread medicine. Here Kyempa is reminding his readers of a female who is essential to medicine’s very conditions of possibility. But this is tempered by the further specification that Kyempa is at pains to make: that such bodhisattvas were actually males who had merely assumed the form of females. The second view has to do with “bliss-void method and primal awareness”—a euphemism for the male and female couple in tantric sexual yoga.³⁸ He does not specify whether he is referring to actual women or a visualized consort—tantric practice knows both—but the statement is fully applicable to real women with whom men engage in sexual yoga and who facilitate bliss.³⁹

Such reparations are kicked up a further critical notch when Kyempa adds a final point: “One needs to understand in terms of the context.”40 This would remind the reader that women are precious in some contexts even if they may be inferior in others. It makes an important intervention by removing the option for an absolute female nature to be fixed for all time. The statement fits into a growing pattern in medical thought already seen in previous chapters of this book. Standing back and recognizing that things have different meanings depending on the way they are being used opens up space for medical knowledge on its own terms. In this case, all three contexts under discussion—the medical vulnerability of women due to their inferior karma, the salvific female form assumed by certain bodhisattvas, and the key role of female consorts in sexual yoga—trade in Buddhist conceptions of the female. Recourse to Buddhist imagery and lore facilitates an epistemic position that knows there are various systems of thought and practice that can confer meaning; the picture of women represented by the Four Treatises’ female pathology chapter is only one item on the menu.

There is another opening gambit in the Four Treatises, at the beginning of the virility/fertility section, that also takes the occasion to make overtly androcentric and patriarchal, if not outright misogynist points. This time we can get a clearer picture of what was at stake, even if the rhetoric is more complex and harder to parse. It is worth going through in some detail, for it brings home the inseparability of medicine and certain instrumental agendas, at least with respect to women and gender.

Rotsa (i.e., ro tsa), an odd term in Tibetan (Skt. vṛṣa, or vājīkaraṇa), names one of the eight branches of medical knowledge in the Four Treatises and in Ayurveda.41 The category is defined as addressing both sexual pleasure and fertility. In Aṣṭāṅga this set of topics is covered by one chapter, but the Four Treatises expands the rotsa section to two, one devoted to the man and one to the woman.⁴² But despite the addition of a special chapter on the female, sexual pleasure is treated only in the male chapter. The female chapter is only about fertility. Moreover, the Four Treatises’ entire view of fertility is presented very much from the perspective of male privilege and male progenitors. Unlike the female pathology chapters, where the misogyny is mostly gratuitous, in the rotsa section patriarchy and androcentrism are foundational to the organization of knowledge. Thus it is more understandable why the section’s opening statement needed to address that explicitly.

In fact, this introductory passage suggests that there was some question afoot about why the androcentrism of rotsa medicine is so definitive. The opportunity seems to have been taken at the outset to foreground the very nature of virility and fertility, and the role of males and females therein. Once again the passage appears to be entirely the Four Treatises’ original invention. The parallel chapter in Aṣṭāṅgahṛdaya’s virility/fertility section contains a lot of the same information as in the rest of the Four Treatises’ male virility chapter, as well as overt androcentrism, if not a triumphalist male voice, but the Tibetan work’s self-consciousness of its androcentrism and patriarchy is entirely missing in Aṣṭāṅga. Nothing in the Indic work is like the case the Four Treatises makes that the male must be the main focus of rotsa—or the distinction it makes between principal and auxiliary topics. This original passage in the Four Treatises thus reflects the social constructions of the particular milieu in which it was written.

The last line actually introduces the rest of the chapter, now focused on the male. I include it for the irony of its insistence that the man is the principal topic of rotsa, despite the immediately preceding lines that have just spoken of the commonality between male and female reproductive issues. Indeed, the entire passage is an exercise in ambiguation, sleight of hand, and doublespeak. I have broken the passage into sections according to my reading of the individual arguments that it brings to bear.⁵¹ Following its circuitous route through patriarchal privilege, sexual prerogative, various contradictions about conception and responsibility for the sex of offspring, and a host of aspersions cast at the female is an object lesson in how rhetoric can be twisted while consistency be damned. And yet it also affords a very clear view of what can fund medical rhetoric. The doggedness of the statement only underscores the power of the social realities to which it is so evidently speaking.

The passage identifies the two aims of rotsa to be the fulfillment of desire and reproduction. This is natural enough. But here both are put to work to defend patriarchy and androcentrism, as the passage moves into why the two sexes are unequal, one the principal and the other an auxiliary, in favor of the male.

After defining rotsa and then asserting its main thesis that the male is its principal concern, the statement’s first main point is to defend that thesis in terms of performance. In order for sex, and reproduction, to happen, first of all he has to be able to perform. It’s a sine qua non. Even if he is surrounded by a harem, it is all up to him. Therefore, rotsa’s primary task is to render him virile.

Performance is fair grounds for focusing on the male. But then the text adds a quite different reason he is central to rotsa. If indeed his semen is unflawed and plentiful, he can search for a woman to fulfill the desideratum to bear children. The commentators make this more specific. If for whatever reason, his partner cannot bear children, then it is permissible for him to find another consort.52 And that too is why he is central. Here we can note the failure to consider that perhaps she, if fertile, might choose to find another partner herself. Ignoring the possibility that a fertile and ready female would abandon an impotent male and search for another one who could impregnate her, the text only considers his exclusive and asymmetrical social prerogative.

Yet on this very point, which would seem to be about patriarchy, the Four Treatises betrays several further ambiguities. For one, the very key word “son” or bu can mean either “child” or “boy” (the female bu mo, “daughter” is more specific, but its usage does not render all instances of bu necessarily male). Sometimes the sense in the passage is obvious, sometimes it is truly uncertain (and sometimes the commentators will endeavor to specify which is meant). In my translation I have tried to indicate when the alternate reading is also possible.

It may well be that in some cases the ambiguity is strategic. The same can be suggested for the phrase “the means to search for a woman.”53 In the passage translated above, that phrase names the auxiliary topic in rotsa medicine, the part that concerns the woman. But a major clue that something is amiss is the ambiguity regarding the title of the chapter that actually discusses that auxiliary topic. While the Four Treatises’ own list of its contents duly refers to that chapter as “finding a woman,”⁵⁴ in the three earliest xylographic editions of the work, the chapter itself is labeled instead “how to search for [remedies for the condition of] no child [or son].”⁵⁵ The latter would be a more appropriate title and would match the actual content. This second, auxiliary rotsa chapter is all about the medical reasons women might not be able to bear children (or sons) and how to address those problems, in effect summarizing the content of the female pathology chapters, and also paralleling in large part the first rotsa chapter, which provides diagnoses and remedies for the afflictions affecting sexual reproduction in the male. But by the time that Kyempa was writing, the title of the chapter had changed to read “how to find a woman,”⁵⁶ despite the fact that its content has virtually nothing to do with that and the colophon to the chapter continues to call it “how to look for [remedies for the condition of] no child” in all of our available versions.⁵⁷

The new rendering of the chapter title, in addition to reflecting the Four Treatises’ initial list of its contents, is of a piece with the discussion in the first rotsa chapter, which introduced the auxiliary topic in just that way. In short, the Four Treatises—in all of its available editions—indicates not only a pervasive ambiguity in the usage of the verb btsal, which occurs five times in the two rotsa chapters and switches between connoting to look for and to attend to a problem. Far more slippery is the key term bud med, “woman.” Pronounced bumé, bud med is homophonous with, and one consonant away from, bu med, “sonless” (or “childless”). By virtue of a certain sleight of hand, the auxiliary topic of rotsa is alternately labeled as a way to address problems in the female reproductive system and a way to look for (another) woman. It is hard not to see this as an intentional ruse, whereby the reasonable topic of how to address female medical issues is named by an overarching rubric that can, with the addition of a single consonant, be read instead to say how to find a new woman. But whether the pun is really deliberate or merely fortuitous, the point is clear. If the current consort’s ills are not curable, go out and find another—indeed, as some commentators specify further, a very attractive one.⁵⁸ The pun thus became an occasion to reassert patriarchy through a sly confidence: we are supposed to be providing remedies for female reproductive problems, but we know what we can do if they don’t work.

In any event, both readings of the auxiliary topic of rotsa render the female secondary. Medical science would address any problems with her body only secondarily to his ability to have sex. The next lines of the passage continue in the same vein, offering a few comments on the nature of women in general. Her role is to hold his seed and make it grow. This line takes away from the woman the function of having seeds for reproduction herself, despite the fact that the Four Treatises’ own embryology chapter makes clear that she does have reproductive seed, and despite what the very same passage says just a few lines down.59 This is perplexing. But the fact that she merely holds seeds (the modifier “merely” is added by all three commentators) is adduced as one of the reasons, again, why the principal of rotsa is the man.⁶⁰ The Desi makes it even more clear when he says that “any” woman can perform the function of holding the seed.⁶¹ When the rest of the statement turns to a seemingly quite disparate point—that girls don’t hold the generational lineage of the father—we start to see the logic (or shall we say again sleight of hand?). Even though the argument has switched from the mother to the daughter who can’t hold the father’s line, something fundamental about all females is being discussed, something that would reflect on the mother as well.

The point, and probably the entire passage, trades on a social reality: women don’t hold the “generational lineage of the father.”⁶² The passage already invoked the importance of reproduction for the “family lineage,” a term that also has patrilineal connotations.⁶³ Tibetan society, at least in the area around Yutok’s homeland in the twelfth and thirteenth centuries, would seem to have been patrilineal. It is also explicit that the professional lines of inheritance in medicine were patrilineal.⁶⁴ So if females cannot hold the family line, they are not the main concern of fertility and virility treatments. Thus is rotsa about men making boys. The sleight of hand is that an already shaky claim about who is responsible for reproduction is bolstered by an irrelevant point about lineal descent—that is, irrelevant if you were only interested in the medical issue of reproduction, quite apart from inheritance and family issues. But of course reproduction and family are not separable. Not in the real life of societies, and not in medical knowledge. In this instance, patrilineal prerogative trumps biological facts.

The argument moves on to another point in the next line, and here the contrast is stark between the two sexes. When properly primed, he is a veritable sex machine. Meanwhile, on her side, another vulnerability actually renders her responsible for the failure to reproduce. Having given him the compliment of being able to “do it” (spyad) with them all—suggesting again that many woman are options, while he is at the center of the harem as agent and subject—suddenly the passage moves into the realm of moral quality. The reasons for her weakness are her poor karma, power, and merit. The term power (dbang) is interesting and would seem to refer to her lower social status, but the commentators understand it rather as an auxiliary to karma.65 A discrepancy between the karma of the father and mother will have an effect on the sex of the child: even if the father’s karma is right, if the mother’s does not match it, no child (which likely means no son) will appear. Either way, the point is unflattering to her. Perhaps that makes up for the fact that the line nonetheless seems to presume that she has responsibility for the sex of the child, if bu here really means boy: if her karma is good it will be a boy, if it is bad it won’t be a boy. But even if bu simply means child, and the line has to be read that no child at all will appear if she has poor karma and merit, would that not imply that she should be a main topic of rotsa? Shouldn’t the chapter suggest ways to improve boy- (or child-) conceiving karma? No, the social reality kicks back in again in the next line. The only thing that her moral inadequacy means for rotsa medicine is that he is entitled to search for a better partner, as already stated.⁶⁶

The two metaphors in the next line continue to take away from the female the fact that she too has seed that makes an infant. Here probably drawing on another old Indic conception, found for example in Manusmṛti, whereby the female is a field and the male the seed planted therein,⁶⁷ the metaphors as adapted here are at odds with the Four Treatises’ rhetorical agenda to make the woman secondary, since the wording and rhythm of the line actually puts the parents in an equivalent position. The two things that can go wrong are that he has no seed and that her field is bad. That would seem to mean that even though the female does not produce seed, she still has responsibility for the success of the reproduction project. But this still does not raise her to parity in rotsa. Only the early modern commentators make the parity explicit, noting that the set of metaphors “looks back and forth” between both male and female. The commentators also make explicit that the first image refers to a flaw in the male, the second to a flaw in the female.⁶⁸

By the last line of this opening passage it would seem that even the author of the root text has realized the leap of logic in insisting, against all evidence (including his own), that the male is the principal agent of reproduction. Or perhaps it is a return of the repressed. He is now bent on making a series of very explicit points about male-female parity with respect to rotsa. They both have gonads, they both have refined distillate, and they both have seeds, directly contradicting the metaphors just supplied. One’s seed is white, one’s seed is red. The ailments of rotsa are explicitly said to be common to the pair, male and female.⁶⁹

And yet despite granting this point, rotsa is principally about the male. Period.

In its endeavor to position the male’s perspective as preeminent, the Four Treatises sometimes reconstrues the material it is taking from the Aṣṭāṅga. Whereas the latter makes the male the tree without branches, here it is the female, with the passage also suggesting that she is at fault. The scene painted by the Four Treatises suggests an anxious checking of the woman’s belly for the first signs that she is pregnant, and desolation when it can only be concluded that she is not. Since “to rely” implies to have sex with, the problem here is not his performance, yet what ensues in the chapter is a set of instructions on how to have good sex.

There are conditions that will put him in the mood and get him ready. Once again, the imagery restates the Aṣṭāṅga’s conception of the conditions for sexual arousal. ⁷¹

The passage continues with the problems the man might be having with either dried-up or overflowing semen. The remedies run from food and medicine to actions and special procedures; many of them have parallels in Aṣṭāṅga, but there are also differences.⁷⁴ It is touching to see, among the remedies for dried-up semen, aphrodisiac actions that in the modern West we usually think will cajole and arouse women:

These fantasies of male potency—again echoing the words of the Indic Aṣṭāṅgahṛdaya but hardly anathema to Tibetan sensibilities—are promises that punctuate the various recipes for virility, and take over the horizon as the discussion proceeds. By the final summary of why rotsa techniques are needed—once more closely based on lines from the Aṣṭāṅga—the celebration of male sexuality is paramount.

While the goal of reproduction has not fallen out of the picture, the emphasis is on carnal pleasure. In the end it would be difficult to say whether it is desire for sexual prowess or the maintenance of patrilineal and patriarchal power that drives the Tibetan medical discussion of fertility and virility. Suffice it to comment for now that with such goods hanging in the balance, the appropriation of pride of place by the male authors of the Four Treatises can hardly be a surprise.

Many of the Four Treatises’ issues regarding the female reproductive system and delivery problems are shared in broad strokes with Aṣṭāṅgahṛdaya.80 But the presentation is different, in both organization and the materia medica. Probably much of the information in these chapters, unlike the embryology, which is closely influenced throughout by Ayurveda, represents Tibetan practices on the ground. I can only provide here a bare overview of what Tibetan medicine knew about the female reproductive system. Actually I am most interested in a few examples when the medical theorists are aware of what they don’t know, and how they struggle to redress that. These are found not so much in the Four Treatises itself but rather in a few telling statements from the early modern commentators. In particular I will attend to those moments when they realize they need to resist ideal system and instead attempt to account for individual difference.

Most of the first two chapters of the female pathology, 74 and 75, are taken up with conditions of the uterus, or womb.81 The chapters also address the effect of humor imbalances on the female reproductive system. Now we find a far more balanced etiology. No longer is the embodied female plight exclusively the result of her bad karma or moral disposition; it is equally the product of the food she has eaten and the way she has treated her body, not to mention the influence of demonic outside forces. These conditions are organized around excesses in the humors, the standard etiology of all kinds of disease throughout the Four Treatises. But note the exceptional fact that in the female pathology branch, blood is added as a fourth humor to the usual three. This rarely happens elsewhere in the Four Treatises.⁸² I am not certain where the shift is coming from: it might have to do with the key role of menstruation in the female reproductive system, although what exactly is meant by blood as a humor and how that relates to both the menses and the blood that flows in the veins is a complicated question.⁸³ In any event, excesses of blood (khrag tshabs) qua fourth humor are traced, predictably, to menstrual irregularities, which will cause blood to collect abnormally in various organs. Symptoms include pain in the back and waist, sensations in the uterus and vulva, skin conditions, various excretions from the vagina, swellings of the face, general pains in the bones, dizziness and feelings of numbness and chill, and genital itches. Mental conditions are mentioned too: a sense of unhappiness, forgetfulness, and feelings of faintness.⁸⁴ Selby, speaking again of Ayurveda, has speculated that such subjective descriptions of experience, as opposed to the external signs that the physician himself can describe, suggest women’s contribution to medical knowledge.⁸⁵

Treatments proceed largely in the form of douches, mostly administered to the vagina. The ingredients are specific to Tibetan food products and reflect detailed knowledge of animal husbandry.⁸⁶ The seventy-fifth chapter also discusses related ailments that afflict the body’s channels, along with various kinds of tumors (skran), and finally kinds of parasites (srin bu, lit. “worm”) that inhabit the uterus. The parasites in turn are divided into those that are “aroused” and those that have become “angry,” or irritated. The way the symptoms of worms are described, including itching, unstable mind, a desire for sex with men, and a bad genital smell, echo familiar misogynistic imaginations of exaggerated female sexuality. While the same general class of parasites is also identified in the fiftieth chapter of the Instructional Treatise as the cause of other illnesses for both males and females, such as infestations in the stomach, intestines, genitals, and blood, and as inducing leprosy, their characterization in the female pathology chapters seems gender-specific. This is evident in the case of the irritated parasite. If such an infected woman does not have a chance to “meet” a man, she will use a finger or small piece of wood inside her vagina, making the parasite even angrier. The treatment is to have sex with men, as well as to apply certain compresses that contain semen.⁸⁷

The third chapter on female pathology, seventy-six in the Instructional Treatise, has almost entirely to do with kinds of miscarriage, induced labor, abortion, and problems of delivery. It gives detailed recipes and instructions for the physician.

I already noted that the Four Treatises also addresses female conditions elsewhere than the three chapters labeled female pathology branch. The forty-third chapter in the Instructional Treatise on the female genitals is closely related to two chapters on the male and female genital area in Aṣṭāṅgahṛdaya.⁸⁸ It covers the female reproductive system as a whole, including conditions that impede pregnancy caused by too much sex and other improper behavior.⁸⁹

Information on female pathology is also provided in the second rotsa chapter, already discussed. This reviews obstacles to conception caused by demon possession and by the application of birth control substances.90 It also addresses barrenness and its particular symptoms in menstrual patterns. And finally, the embryology chapter too reviews a range of humor imbalances that render the reproductive fluids infertile, and also describes the appearance of normal female and male sexual fluids.

There is a plausible description of menstruation in the embryology chapter, suggesting some unblinking observation of this monthly condition of women.

This knowledge too is closely based on Ayurvedic tradition; it basically puts together information from several verses in Aṣṭāṅga.⁹² Much in this account accords with modern knowledge about conception, including a notion of something like the fallopian tubes, an idea that has a long history in Ayurveda.⁹³ For the Tibetan physicians the location of these two channels was the object of some confusion. The early commentary Black Myriad already tries to fill out the picture by maintaining that “two channels come out from the left and right of the samse’u and connect with the mouth of the uterus. [The menstrual fluids] pass through there, and then collect for a month in the uterus.”⁹⁴

Black Myriad expands the Four Treatises’ statement by specifying that the two channels issuing into the uterus are connected to the samse’u, an organ not known to Ayurveda. The Four Treatises itself mentions this organ several lines later when the two channels come up again.⁹⁵ The samse’u was long a source of consternation for Tibetan medical knowledge, but in both the debate over the need for a separate female pathology section and the convoluted introduction to the rotsa section it is very clear that the samse’u is thought to be common to males and females.⁹⁶ In the present context, however, talk of channels from its left and right issuing into the uterus is specific to the female. By virtue of adding the samse’u the picture becomes even closer to the modern biomedical conception of the fallopian tubes, although the Tibetan ovary appears to be conceived in the singular.

The connection of this female gonad to the two channels and the uterus, and the role of all of them in menstruation and the conception of babies, remained sites of medical knowledge in need of further clarification. Kyempa spends time locating the channels leading out of the female gonad, but cites among other works an autocommentary to Aṣṭāṅgahṛdaya that does not refer to a gonad and instead places the source of the channels inside the uterus, claiming that these issue into the vagina (mo mtshan).97 The picture painted by the Four Treatises itself is in any case not entirely in accord with the modern conception of the fallopian tubes. When the two channels come up again later in the passage, they are said to connect the uterus to the navel of the infant, thereby feeding it with the refined fluids issuing from the samse’u.⁹⁸ This leads Kyempa to specify that the two channels are themselves part of the samse’u and serve to connect this organ on the left and right to the inside of the uterus, where the fetus can access the gonad’s nutrients.⁹⁹

Zurkharwa for his part contests Black Myriad’s specification that would have the fallopian tube-like channels issuing into the “mouth of the uterus” (bu snod kyi kha). Instead he maintains that the mouth of the uterus faces downward, i.e., at the bottom of the uterus, which would be the cervix.¹⁰⁰ The Four Treatises statement itself seems to say that the blood arriving into the uterus through the two channels enters through the “door” of the uterus, not the mouth. Zurkharwa also contests the idea that the menstrual blood collects in the uterus over the course of a month. Rather, he says that such material collects in the samse’u itself, located above the uterus,¹⁰¹ over the course of sixteen days. At that point it enters the “enclosure” of the uterus through the two large channels that run from the samse’u to the right and left of the uterus at its door. As soon as the blood enters, he specifies, the mouth of the uterus opens and the blood drips down, i.e., from the uterus into the vagina.¹⁰² He also agrees that the same two channels that bring the menstrual blood into the uterus serve to feed the fetus when a woman is carrying it. That is the reason a woman does not menstruate when she is pregnant.¹⁰³

Zurkharwa and his predecessors were refining knowledge already conceived in the Four Treatises and Ayurvedic texts, even if not with the exactitude of Gabriele Falloppio’s (1523–1562) specification of the fallopian tubes, in turn suggested long before in Greek medicine by Herophilus and others. But at least Zurkharwa and Kyempa were seeking scientific precision. In other respects, however, Zurkharwa betrays a residual allegiance to ideal system, as when he ties the menstrual cycle to the phases of the moon.104 When he maintains that the “red element” collects from the sixteenth day of the month until the new moon, when the menstruation process commences, he implies that all women menstruate on the same day, something that surely would have been contravened if he had cared to check women’s empirical experience. Zurkharwa underlines his conviction when he also states that the connection to the moon’s phases is why the female cycle is called menstruation, i.e., zla mtshan, lit., “sign of the moon.”¹⁰⁵ He adds that the white element, which increases in the woman like the moon in the first half of the month, is emitted in the middle of the cycle, which shows that he was aware of the discharge that many women have at the time of ovulation, the periovulatory mucus produced from the cervix.¹⁰⁶ The fact that this discharge is not mentioned in Kyempa’s commentary or the others of which I am aware, including Ayurvedic works, might mean that it is an original contribution, based on Zurkharwa’s or colleagues’ clinical experience. At the least, we can say that knowledge of women’s bodies continued to be refined in his day.

We have already seen a second description in the Four Treatises, at the beginning of the first female pathology chapter. Removed from its misogynist context, it represents another medical account of menstruation.

This description of menstruation differs from the one in the embryology chapter. It places the onset of a woman’s period at the age of thirteen, at odds with the Ayurvedic idea that it begins at twelve. There was apparently some dissent in Tibetan medical circles on this question, and several editions of the Four Treatises have the female pathology description of menstruation reading twelve as well.¹⁰⁷

Kyempa seems intent on getting it right. He brings up the statement from the female pathology in the context of commenting on the embryology, aware that there is information on female medicine in different parts of the Four Treatises. Kyempa corrects the age provided by the female pathology, which in his edition did read thirteen, and comes up with the new specification that menstruation actually begins at twelve and three months. His logic is that the claim that it begins at thirteen is based on counting age from conception, whereas he would count from birth.108 Perhaps he is trying to reconcile the two statements in the Four Treatises, since twelve years and twelve years plus three months are almost the same. In order to do so, he has had to set aside the Tibetan convention of counting age from conception. In fact he has not really reconciled the two and still differs from the embryology chapter’s count, if not by much, even though he displays a certain precision and originality in the process. In any event, he is still participating in ideal system. Like the root text, he is saying that all women get their periods at the same age (whatever that is), hardly a claim one would expect of an empirically based medicine.

And yet we also find a rather different epistemic position immediately contiguous to this discussion. Kyempa closes his section on menstruation with the following caveat: “However, the particulars regarding the amount [of menstrual discharge] that is produced, and the increases and decreases having to do with one’s age, and so on, should be understood to be numerous, since they are a function of one’s karma.”¹⁰⁹ Here Kyempa has gone on to broach issues not in the root text at all, which never considers lightness and heaviness of periods and their shifts over the course of a woman’s life. In so doing he points out a number of kinds of individual difference in menstrual experience. Zurkharwa too briefly considers individual difference, and flirts even further with questioning the root text when he adds the caveat that it is “most women” who menstruate from the age of twelve to fifty.¹¹⁰ A small modification, but it does signal, once again, Zurkharwa’s suspicion of generalized abstraction at the expense of individual irregularity.

Note too Kyempa’s use of the category of karma. Unlike its invocation to naturalize gender hierarchy or to explain a particular pathological state, here a Buddhist notion is used to elucidate a scientific observation that the earlier medical system did not offer. In this instance, karma serves to account for a second-order principle of unpredictability and human variation; what is observed in the clinic is irreducible to ideal system.¹¹¹

The Four Treatises’ main statement on conceiving a child in the embryology follows directly on its statement about menstruation. Again, it is expressed in its own terms, though it is closely informed by Ayurvedic concepts.¹¹³ Actually its wording is somewhat confusing, and Kyempa and Zurkharwa spill much ink making sense of it.

Kyempa endeavors to show that the numbers these lines give for the days on which a boy or girl will be conceived are counted from the fourth day of the woman’s cycle. That means that the statement that she can conceive a boy on the first, third, fifth, seventh, and ninth days actually mean the fourth, sixth, eighth, tenth, and twelfth days of her cycle, i.e., if counted from day one. The same adjustment applies to the days when a girl will be conceived.¹¹⁵ Most of all, Kyempa’s solution resolves the problem that the Four Treatises statement contradicts the Aṣṭāṅgahṛdaya, which claims that boys are conceived on even days and girls on odd days. The pertinent lines there read,

The upshot then is that both Aṣṭāṅga and the Four Treatises have boys conceived on the even days and girls on the odd days of a woman’s fertile period. Other than the Four Treatises’ disparity in wording, the Tibetan commentators don’t question the main assumptions here from Ayurvedic tradition, such as the idea that a woman’s fertile period begins on the fourth day after menstruation begins, quite at odds with the modern biomedical account that usually puts the earliest moment that a woman can become pregnant at around the seventh day. Only in the twentieth century did a prominent traditional Tibetan medical scholar think to correct the Ayurvedic and Four Treatises’ large contravention of empirical evidence.¹¹⁸

I will continue discussion of the sex of the child, which also includes the third sex, the ma ning, in the following section. For now, note what we can extrapolate regarding the Ayurvedic/Tibetan picture of menstruation and conception in the context of the embryology. There is some knowledge of discharge mid-menstrual cycle, but neither Ayurveda nor Tibetan medicine appears to have an idea of ovulation. They explicitly consider conception to result from the union of the father’s and mother’s seed, and both discuss how possible defects in either the male or female reproductive substances can impede pregnancy.119 What these female reproductive substances are actually supposed to be, and what the relationship is between “blood,” “menses,” and the reproductive substance as such remain vague. But there is no question that both the Four Treatises and the Ayurvedic tradition consider the female substances, whatever they are, to contribute reproductive material, just as semen does.¹²⁰ Zurkharwa quotes a Buddhist tantric work to make the point clear: “Here, when the two organs unite, the semen that falls into the secret lotus and whatever blood is in the female organ (bhaga) are what are said to be seed.” Then he reiterates the point himself: both the semen of the father and the blood of the mother are called “seed.”¹²¹

Zurkharwa also elaborates how the menstrual cycle plays a crucial role in conception, drawing on Aṣṭāṅgahṛdaya and the Ayurvedic understanding of the period of fertility.¹²² The uterus is only open for twelve days from the onset of menstruation, during which time the female can “hold the seed” of the male. After that, the mouth of the uterus closes, and she will not be able to hold his seed. In any event, the male’s semen will not desire the inside of the uterus and will reverse its path and come out. Zurkharwa is equally clear that the presence of her own menstrual substances in the uterus during this same period is just as critical to the process. In short, one must wait for the appropriate moment in the menstrual cycle in order for the woman to get pregnant.¹²³

Other sections of the Four Treatises support a view of joint contribution to the body of the fetus as well. It is one of the basic assumptions of the pulse chapters, a disparate segment of Tibetan medicine with likely Chinese rather than Indic sources. There the sex of the offspring is determined by how the mother’s and father’s pulses interact.124 Only one passage in the Four Treatises, in the rotsa section, implies that the father alone contributes the substance that creates a fetus, but as we have seen, that statement is overdetermined by a set of social agendas around retaining control of sexuality and family lines.

A lot more could be said on the Four Treatises’ conception of the female in physiological terms, including all the material on the red and white seminal substances, how they are sexually differentiated, how they are not, and how in Tibetan medicine the samse’u produces them both. But leaving that aside for another study (and in cognizance of the enormous work on related issues in Indian medicine already produced by Rahul Peter Das),¹²⁵ I turn to another principal ground for sexual identity: the genitals. These are often called “sign” (mtshan ma, Skt. nimitta) for both male and female, presumably in light of the genitals’ indexical connotation of the person so marked. Here, in contrast to the physiology, knowledge of the female genitalia seems scarce, at least in the Four Treatises.

Other than the many references to the uterus, along with the door at its top and the mouth at the bottom, there are only a few scattered specifications relevant to female genital anatomy. The female genital chapter of the Four Treatises mentions the mouth of the urethra and perhaps a kind of mouth of the vagina that is bent.¹²⁶ The female pathology chapters mention a “mouth to the channel,” which also seems to reference the vagina.¹²⁷ In one instance the locution “outer flesh-skin opening” is used, which probably refers to the vulva.¹²⁸ Usually just the general term “female sign” is used.¹²⁹ We saw in chapter 4 that Zurkharwa resorted to the prosaic functions of the tantric channels, in turn influenced by Indic kāmaśāstra, to describe her sexual plumbing.¹³⁰

And yet the most salient metaphor for female identity, a term used broadly in medicine as well as most other Tibetan literature, is cast in terms of genitalia—albeit what she lacks. Bud med is an old and pervasive word for woman, or sometimes the female in general. (A more recent term for woman, skye dman, lit. “low birth,” is already foreshadowed in the Four Treatises’ female pathology opening.)131 Apart from the most basic of all—mo, “female” and its opposite pho, “male”—bud med is used most frequently in the Four Treatises. Its etymology is somewhat of a mystery. Bud is probably the past tense of ’bud pa, a verb that is usually transitive but can also be intransitive when it means to fall or be lost. The following gloss is found in the Desi’s history of medicine:

During the time of the first eon, when the male and female organs were close to emerging, at one point a protuberance sort of thing in a lumplike shape grew in some. It became the male sign and thus he is called “grown.”¹³² In some it fell off (bud nas) and so they became ones who possessed a hole that lacked it. Therefore they were known as “fell off and gone” (bud med).¹³³

In brief, the bud med is the one with no penis. The Desi’s etymology is likely fabricated, but it reflects the term’s semantic resonance in common understanding. Here, then, the foundation of female identity—as in so many other places worldwide—is about a lack, an absence, now specifically in anatomic genital terms.¹³⁴

A second term used in both the female pathology and virility/fertility contexts is harder yet to parse. Za ma, which I translated above as “deficient,” often renders the Sanskrit term ṣaṇḍha, but not literally. Both terms have a complex semantic range, and they do not overlap. In Tibetan the more conventional sense of za ma is “food,” but it is also a term for a female. One definition adds that it has to do with a lack of capacity to perform sexually.¹³⁵ Performance issues disqualify the female for primary status in the rotsa section. The reference to such dysfunction reminds us that both za ma and Sanskrit ṣaṇḍha are not only terms for the female but also names for sorts of eunuchs.¹³⁶

In fact, the medical treatment of the eunuch—and the other sexual anomalies that I am calling the third sex—is especially generative for this study. Not only is it intimately connected with conceptions of the female, it also reveals some basic aspects of gender conception more generally in medicine. These become clear in the striking difference between Tibetan medical and Buddhist conceptions of the third sex.

Both Indian and Tibetan medicine clearly recognize the fact that the possible sexes of an infant are three, not two. Such a trio might seem to be a fixed trope of its own until we realize that the third sex is a very porous and elastic category that in a sense does not stand as a proper category at all. Nor it is singular by any means. Rather, the third sex stands for all of the aberrations in between the two normative poles of male and female. It represents a long-standing medical perception of the full range of human diversity with respect to genital anatomy.

As early as Carakasaṃhitā it is assumed that there are three possible sexes of a child: male, female, and neuter (lit., “not male,” napuṃsakam).137 The latter is perhaps the most common Indic term used for the third sex, but a closer look reveals a plethora of conditions that come under this heading, and a plethora of labels.¹³⁸ In one passage, for example, Carakasaṃhitā lists eight kinds of aberrational sexual identity.¹³⁹ Ṣaṇḍha is one of the words in Indic medical sources for a kind of abnormal or third sex.¹⁴⁰ Such conditions are largely ascribed to congenital causes.¹⁴¹ In Tibetan the term of choice for the third sex is ma ning, another strange word of unclear etymology. I use this term in the following pages, alternating sometimes with the neutral phrase “third sex.” Neither “neuter” nor “hermaphrodite” suffices. Note too that there are significant differences between the Tibetan and Sanskrit semantic ranges for any of the words used for the third sex. It would be misleading to gloss the Tibetan discussions on the ma ning as napuṃsaka, or paṇḍaka, to name another one of the common Sanskrit analogues. Each of these terms has different meanings in different contexts.

Sexual identity (rten, or “receptacle”) is the first and most basic category by which the body is classified in the Four Treatises.¹⁴² It reduces all of the anomalous third sex varieties to ma ning. This means there are three human sexes: male, female, and ma ning.¹⁴³ The same trio recurs in the embryology chapter, which speaks of three possible kinds of children. Ma ning is what will issue when the mother’s and father’s reproductive substances are in balance.¹⁴⁴ The impending birth of a ma ning instead of a boy or girl can be discerned when the mother’s belly does not lean to the right or left but stays in the middle.¹⁴⁵

Not all sexually relevant medical discourse references three sexes, however. The Four Treatises can also conceive only of the classic two, as is certainly the case in the exclusively heterosexual fertility/virility section and in the vision of sexual identity at the start of the female pathology section.146 Even the discussion on the birth of children that so clearly anticipates the possibility that any one of the three sexes will be born goes on in a contiguous passage to count out the days of the menstrual cycle when a boy or girl is likely to be conceived, failing to specify when the third-sex child is conceived.¹⁴⁷ In the Four Treatises’ basic passage on pulse type, which Tibetan medicine uniquely classifies as tripartite—male, female, or “bodhisattva” (here a euphemism for ma ning)—the third-sex person as such is not mentioned.¹⁴⁸ And in yet another passage the Four Treatises classifies kinds of diseases in terms of men, women, children, and the aged.¹⁴⁹ While these examples might suggest that ma ning is not really considered a type of real person, one that medicine would treat, the failure to mention the third sex also has to do with its status as aberration from the male and female ideal types. In other words, it is often omitted because it does not really constitute a category on its own terms. The influence of long-standing categorical binaries, such as the red and white substances, light and dark, and many other gendered pairs, probably tipped the medical treatise back into a heterosexist conception of two sexes only. And yet when we get to one of the main terms that the Four Treatises coins to name sexual identity overall, “receptacle,” the standard conception is three. We also know that Tibetan societies understood actual persons with anomalous genitalia to belong to this third sex.¹⁵⁰

“Receptacle” is a very general concept in Tibetan. It often denotes something physical that is the basis or support for something more complex and culturally coded. In medicine the notion of sexual identity as receptacle has to do with the body, the basis for a much larger concept of the person that includes gender features as well as many other dimensions of human life.¹⁵¹ When the third sex is defined in the context of the three kinds of receptacle, it has primarily to do with genital anatomy. Zurkharwa glosses the first two kinds of receptacle with the familiar terms. The male is the man (skyes pa); the female is the woman (bud med). But the third, ma ning, is the one who is “not definitely either of the first two.”¹⁵² He goes on to specify that there are three main kinds of ma ning: one who has two sexual organs, one who has no sexual organ, and one whose sexual organs change back and forth monthly.¹⁵³ In this scheme, then, male and female constitute stable identities recognizable through the shape of their genitalia; this stability is highlighted and bounded by the possibility that someone could have a genital identity that was indeterminate, or not definite (ma nges pa).

Being difficult to define endures as the basic nature of the third sex. Indeed, the ma ning or Sanskrit paṇḍaka is sometimes defined as someone who is not definable, or as already seen from Zurkharwa, as one who is not definitively either a male or a female.¹⁵⁴ As one early medical writer pertinently put it, the ma ning is the one who has no opposite.¹⁵⁵

This category of noncategorizable sexual identity plays differently in medicine than it does in Buddhist paths of religious cultivation, where it has a consistently negative profile.156 The third sex is highlighted early in Indian Buddhism within the context of monastic discipline. Kinds of third sex conditions are included in the list of factors that disqualify a person from receiving monastic ordination.¹⁵⁷ Postulant ordinands are physically examined on just this matter. Passages in a variety of sūtras also warn against preaching the Dharma to the third sex, or even giving them donations, and they are said not to be able to meditate or do other kinds of religious practice.¹⁵⁸

The term paṇḍaka emerges as the main Sanskrit word for the third sex in Buddhist texts.¹⁵⁹ By the early centuries C.E. a list of five kinds of paṇḍaka was consolidated. These can be roughly rendered as 1. a congenital neuter; 2. one whose sex changes from male to female and back again every month; 3. one who is only aroused by special kinds of sex; 4. a voyeur; and 5. a castrated eunuch.¹⁶⁰ Note that some of the members of this list are in the anomalous sex class on the grounds of the nature of their sexual desire and/or practice, in addition to anomalies regarding their organs as such.

The question of why the third sex was denied ordination in Buddhist monasticism is complicated, but I think the matter goes far beyond any aspersions that were cast about its sexual orientation, such as that the third sex person was homosexual. For one thing, homosexuality is attributed to men, women, and paṇḍakas in monastic literature, so it is not the defining feature of the paṇḍaka.¹⁶¹ A better clue might have to do with the association that the third sex has with the second sex. This line of thought also leads to a notable intervention that Tibetan medicine makes into the notion of the third sex.

The Tibetan conception of the female as one who lacks a penis already suggests her affinity to at least some kinds of third sex. Ayurvedic sources, for their part, hint that there is an “unmanly” character of the third sex.¹⁶² Some also recognize that there can be both male and female ṣaṇḍhas.¹⁶³ The paṇḍaka class as construed in early Buddhist monastic texts has a lot to do with problematic sexual functioning, including female varieties, such as problems with sexual organs or menstruation.¹⁶⁴ Particularly telling is the fact that the very list of female dysfunctions that render her sexually anomalous and thus prevent her ordination is almost exactly the same as an early list of insults that monks sometimes direct at any woman.¹⁶⁵ This suggests a close affinity between the third sex idea and misogyny. Women are said to have almost been excluded from ordination themselves in the early moments of Buddhist history, and were allowed in only after special rules guaranteeing patriarchal hierarchy were instituted.¹⁶⁶ Thus are there mounting parallels between the third and second sexes.

I have argued elsewhere that the undecidability, instability, and softness associated with both the female and the third sex were anathema generically to the “order” of monastic discipline. This set of features is germane to the connotations of the third sex category even beyond its defining genital specifications, and not only vis-à-vis Buddhist monasticism. We also see the metaphorical significance of the third sex as soft and unstable in Tibetan grammar, where the trio of male, female, and the third sex names important categories for verbal sounds (as they do in Sanskrit for noun gender). In Tibetan grammar ma ning sounds are singled out for their changeability, a crucial feature for phoneme construction, and obviously mirroring the anatomical anomaly of one of the kinds of genital ma nings.167 Tibetan medicine also provides a number of cases where the trio of male, female, and third sex is used taxonomically. Here, in another key debate between Zurkharwa and Jangpa Tashi Namgyel, the slippery distinction between anatomical sex and its metaphorical or gendered resonances becomes a place to draw a line in the sand between the disciplinary and/or soteriological associations of the third sex and those of medical science.

The ma ning label was used to classify things that are not about sex at all, in both Tibetan medical and tantric physiologies. Early works list male, female, and ma ning as the three kinds of pulse, inhalation,¹⁶⁸ winds,¹⁶⁹ yogic channels,¹⁷⁰ and even digestive juices.¹⁷¹ The three kinds of pulse, however, receive special attention from the medical commentators. I think that is because the seemingly metaphorical invocation of the three sexes in the pulse system is not neatly separable from the fact that these categories also reference sexual identity. But neither are the two senses collapsible. That undecidability poses interpretational challenges. In Zurkharwa’s purview, it serves to elicit an explicit category of gender.

The relevant passage comes right at the beginning of the Final Treatise, when after a brief overview of kinds of illness and treatments, the text introduces its important section on pulse diagnosis. There is an initial discussion on how to prepare for the exam, and instructions on which fingers the doctor uses for which organ and on which spots on the patient’s arms. The latter was at the center of the heart tip debate studied in chapter 5.

The text then introduces the first and most basic distinction in kinds of pulses:

It is pretty interesting to find the Four Treatises employing the very valorized Buddhist term “bodhisattva” as a gloss for the ma ning class.176 Recall, the ma ning is excluded from taking Buddhist monastic ordination and is even deemed unsuitable for religious practice altogether—a harsh judgment indeed. Surprisingly, no medical commentator has anything to say about the anomalous medical usage of the term bodhisattva for ma ning pulse. I can add that the several Tibetan scholars whom I queried orally about the term all seemed uncomfortable with the question and brushed it away. It is clear that the gloss signals a very different valuation of the third sex category in medicine, in sharp contrast to its pariah status in Buddhist contexts.

But do the pulse categories refer to sexual identity, or are they only being used metaphorically as taxonomical devices? Although the passage introduces the taxonomy in terms of “receptacle,” or sexual identity, the pulse types are not tied to the analogous sexed people.¹⁷⁷ That ambiguity yields important insights. Consider first the bodhisattva/ma ning’s overall profile in the passage. As elsewhere in medicine, the ma ning signals a middle point between two extremes. Here it denotes a balanced pulse between two more extreme options—a rough and thick pulse and a fine and quick one. The notion of balance is germane to the entire conception of health in Tibetan medicine. It is thus not surprising that medical tradition thinks that people with such a pulse will be healthy and have long lives. However, the passage also conceives a complex social destiny for people (or couples) with a bodhisattva pulse. They will be well regarded by the powerful, but will have problems with their family and inferiors. Now such a destiny would seem to pertain more to a person with ma ning genitals than pulse per se. If we can venture that the ma ning-sexed person is akin to a eunuch in Chinese society, or perhaps has a status like that of a homosexual, we can imagine scenarios in which indeed such a person did well in elite contexts but was resented by the common folk and relatives. The medical passage evinces nuanced appreciation of the vulnerable position of people with anomalous sexual status. Thus does it analogize anomalous pulse type with anomalous sex and gender type.

And yet that reading is largely based on inference. The Four Treatises passage explicitly disassociates genital sexual identity from pulse identity, since men can have female pulses and vice versa, and both can have ma ning pulses. Still, it suggests some connection between sex and pulse. The pulse identity of the parents has something to do with the sexual organs of their offspring, although it is not made clear what that connection would be. And those with a bodhisattva—i.e., third sex—pulse will have trouble bearing children and tend to have one at most. That seems to recall the idea of the ma ning as a person with dysfunctional sexual organs—although not fully. The ma ning pulse person has difficulty producing offspring, but it is not entirely impossible.

Such ambiguity drew Zurkharwa Lodrö Gyelpo’s close attention to this passage, taking on what appears to him a badly confused comment by his predecessor Tashi Pelzang. Once again Zurkharwa drives home the point that a medical theorist must be able to distinguish nomenclature and heuristic categories from physical facts. And once again he is probably exaggerating his adversary’s mistakes. But the point he ultimately makes is very significant.

Zurkharwa quotes Tashi Pelzang directly, excerpting several statements. As in the heart tip debate, we have the original passages that he is citing and can compare them with how he represents them.178 But let us first read Zurkharwa’s comment:

In the commentary of Jangpa Tashi Pelzang it says, “The man is the male, the female is the woman, and that deficient one is the ma ning; all receptacles are subsumed into those three.” And, “The male pulse is of the nature of wind, the female pulse is of the nature of bile, and that bodhisattva pulse is of the nature of phlegm: three.” … And the one who has that which is known as the bodhisattva pulse, the pulse that corresponds to phlegm, “does not take the vows, is not an appropriate vessel for profound Secret Mantra, does not have the lot to practice Dharma and so on, has many faults.” And, “When the parents have the same pulse they will give birth exclusively to males, or females. Most children will be in accordance [with the sex suggested by the parents’ pulse]. When a couple with male and female pulse get together exogamously then both [male and female children] will be born. They will come in turns, depending on which [pulse] is strong and which is weak. When a ma ning meets another one there will not be family. If the mind stream changes, it is possible for it also to change.”¹⁷⁹

Note again the irony of the bodhisattva pulse person having no good lot to practice the Dharma. Zurkharwa never picks up on this grossly mixed metaphor, though he could have gone to town on Tashi Pelzang for it.¹⁸⁰ It is consistent with the widespread disparagement of the ma ning in Buddhist works. In any event, it would seem that Tashi Pelzang—or whoever is being quoted here, for it is possible again that Tashi Pelzang’s statement is from someone else—is confusing his training in Buddhist monasticism and scripture with his medical training and errs in importing the former into the latter.¹⁸¹ The blunder creates a striking categorical dissonance.

Zurkharwa takes Tashi Pelzang to task for what he sees as a simplistic equation between sexual identity and pulse identity. He first takes issue with the equation of the deficient za ma with the ma ning, maintaining that the root Vinaya scripture explains za ma as someone whose penis has been removed, i.e., a eunuch, whereas it lays out only three kinds of ma ning, the kind who changes monthly, the kind who has both male and female genitals, and the kind who has no genitals. He seems to be insisting on specificity; we should not gloss over the disparate conditions of differing types of sexual anomaly.182

But this is not Zurkharwa’s main point. He goes on to add what would seem to be two hitherto unarticulated kinds of ma ning types to the foregoing standard list of three: one who has a male organ but cannot use it, and a female kind who is barren.¹⁸³ These two—impotence and barrenness—would be much more quotidian sexual aberrations and far more likely the kind that a physician might encounter. It is surprising that Zurkharwa would put them in the ma ning group at all, which by his day had become standardized as three types. This shows again his interest in empirical conditions rather than the surely rare occurrence, if not entirely mythological character of the standard three (especially the ma ning who switches back and forth between male and female monthly, a possibility already countenanced in a Buddhist imaginaire whereby bodhisattvas and others magically change their sex for salvific purposes¹⁸⁴). But then he adds that it is unsure whether any of these kinds of ma ning will have a ma ning pulse (and now he uses that term explicitly). That is his main point.

It is with Tashi Pelzang’s apparent equation of third sex pulse and aberrant sexual organs that Zurkharwa takes greatest issue. After dealing with what he sees as Tashi Pelzang’s too simple identification of pulse types with humor imbalances, Zurkharwa returns to what he finds “really over the top”: the connection between the ma ning pulse and the failure to take vows. Although he does not say it exactly in this way, I think he is so exercised because of the gross error of assuming that the term ma ning means the same thing in the very different contexts of monastic law and medical pulse. A good historian and empiricist, he insists that words can refer to different things in different contexts. He goes on to apply logic to back up this criticism.

It is not the case that having a ma ning pulse renders one a ma ning. The ma ning pulse that is an examined pulse is not to be foisted onto the ma ning that is about receptacle. If it were, then the statement “It will eventuate that one will come, and then none” [would make no sense]. In that context, since you certainly posit that when a man with a male pulse and a woman with a female pulse can, through the power of that female pulse, have a female child, then how can the person who is able to have sex be the ma ning who can’t take vows? Think about it!¹⁸⁵

Zurkharwa’s language is elliptical, but his point is clear enough. If you understand the Four Treatises’ statement about the sex of the children of couples with various pulses, then it should be obvious that in saying “one will come,” the Four Treatises is predicting that the couple with ma ning pulse would have a child too—albeit probably only one. This should prove that the person who has a ma ning pulse is not the same as the ma ning who is forbidden to take monastic ordination, for the latter is understood as a ma ning by sexual identity, and therefore someone who is not capable—due to defective or aberrational sexual organs—of having sex at all, let alone bearing children. In the view of Buddhist monastic law, persons with genital aberrations can’t have normal sexual intercourse.186 This is the reason Zurkharwa cites Tashi Pelzang’s statement that “When a ma ning meets another one there will not be family.” The fact that Tashi Pelzang says this immediately after discussing the outcome of couples with various kinds of pulse combinations suggests that he is conflating the ma ning-pulsed person with the ma ning-sexed person.

Zurkharwa goes on to drive home the distinction between the sex of the genitals and the sex of the pulse category. He capitalizes on the notion of “mind stream” already brought up by Tashi Pelzang in the last sentence that Zurkharwa quoted. Zurkharwa develops that notion further, with a more radical implication than Tashi Pelzang suggests. The passage provides a prime example of a technical concept from Buddhist scholasticism serving the articulation of a medical question about the everyday body. Zurkharwa writes,

When you say that “If the mind stream changes, it is possible for it also to change,” are you thinking of the male and female organs, or the pulse on the arm? If you are thinking of the organ, then it is not the case that when the mind stream changes, the male or female organ changes. For example, there can occur a woman who has a man’s mind stream, but how does that make her a man? If you are thinking of the pulse, why do you need a change of mind stream? Males with female pulse and females with male pulse occur.¹⁸⁷

Tashi Pelzang seems to have added an unconnected point at the end of his discussion on ma ning. Its implication is not clear, but it has to do with some aspect of one’s ma ning status changing if one’s “mind stream” changes. Zurkharwa asks whether Tashi Pelzang means that the sexual organs would change, or the pulse identity. If the latter, he finds such a claim irrelevant or redundant, since it is already explicit in the Four Treatises’ statement that people can have pulse identities that are at odds with their sexual identity. A change in pulse identity, let alone whatever is meant by mind stream, would not affect the genitalia.

However, the other possibility that Zurkharwa sees Tashi Pelzang suggesting, that the sexual organs themselves would change under the influence of the mind stream, deserves more consideration. And what is this mind stream (sems rgyud, Skt. cittasantāna) that Tashi Pelzang is invoking? Cittasantāna is an old term developed in Buddhist epistemology to denote a person’s basic mental continuum over the course of a life. Given the absence of an essential soul, according to Buddhist doctrine, the mind stream serves as the mechanism whereby karmic deeds and experiences are registered and later reactivated. The notion was devised to provide continuity with the past but avoid the pitfalls of positing something eternal like a “self,” or ātman.188

In the course of working through the nature of human pulse, apparently some medical theorists began to deploy this mind stream notion to name certain personal characteristics, including a sense of gender, not found in the Buddhist scholastic discussions. At present, Tashi Pelzang’s work is our earliest evidence of the deployment of the idea for medical purposes, but this usage may well have a longer history. He talks about it even more than Zurkharwa does. Tashi Pelzang invokes the mind stream in an adjacent passage to what Zurkharwa quoted, where he tries to account for the many factors that affect a fetus in utero. One of these is the parent’s mind stream, itself a product of good or bad karma. That in turn influences the child, including its pulse. Similarly, the predominance of certain humors in the body will also affect the kind of pulse one has.¹⁸⁹ Here the mind stream seems to function in a very general way to affect a person’s overall disposition. In a later passage, Tashi Pelzang adds that someone whose mind stream is dominated by emotional obscuration and stupidity will be a ma ning and have a bodhisattva pulse. However, if that person collects merit and good karma, it is possible that the stupidity will lessen, the mind stream will change, and also the receptacle and pulse will change.¹⁹⁰ Tashi Pelzang believes that pulse, sexual identity, and mind stream are closely aligned and that the latter in some sense determines both of the others. We can also see that he regards the ma ning condition, in whatever that consists, as undesirable.

Why the extra category of mind stream was introduced to account for changes in either pulse or sexual identity is not entirely clear. Perhaps if we get access to other works from Tashi Pelzang’s Jangpa predecessors we will have a better sense of the history of this idea. But even on the basis of what we have seen, the mind stream notion serves to separate out several factors. Zurkharwa goes further than Tashi Pelzang, and quite originally, as far as we now know, makes the mind stream tantamount to a category of gender, explicitly disassociated from sexual identity. A woman can have a man’s mind stream, Zurkharwa opines, but that does not mean that she is a man. It is clear that he means by virtue of genitalia, since he already said he was talking about the sexual organs in his previous sentence. In other words, there is something called mind stream that carries gendered qualities, but it is not the same as genital identity. Moreover, Zurkharwa’s final claim in the passage—that the mind stream need not determine what kind of pulse one has—implies that this mind stream, along with whatever gendered associations it has, is not the same as pulse, even though that also has gendered implications.

We have seen so far at least three categories that relate to sex and/or gender: pulse, mind stream, and receptacle. Receptacle, or genital anatomy, still seems to be the base line for sexual identity, although as this discussion proceeds, the more the gendered dimensions of that identity are displaced onto other, more flexible factors than anatomy itself. Pulse is one of these factors, constituting a gendered dimension of embodiment that has to do with the rhythms and speed of the body’s metabolism. The notion of mind stream as introduced by the commentators suggests yet a further dimension of gender that, at least for Zurkharwa, seems to be free of physical reference. It appears to relate rather to personality type, or perhaps way of thinking, or style; indeed, it appears that “mind stream” in Tibetan today is a vernacular term for kinds of temperaments or personal styles.191 Like pulse, mind stream drives a wedge between anatomy and destiny, although Tashi Pelzang sees it affecting anatomy under certain circumstances.

Tashi Pelzang also tries to line up the humors with gender and pulse in his comments, although that idea does not seem to receive further attention. But when Zurkharwa moves from his critique of wrong views to his own comment on the Four Treatises’ passage he provides one further set of sexually associated personal characteristics relating to pulse. In the process, he makes a breakthrough on the entire question of how those characteristics map onto a person’s genitally based sexual identity—or not—and what status such conventional categories have in the first place.

Once again Zurkharwa falls back on tantric categories to articulate a concept important to medicine. He lines up what are already gender tropes from the Four Treatises’ original pulse doctrine with a further set of gender qualities enshrined in a classic tantric trio. We already saw Zurkharwa and his predecessors invoking the well-known tantric pair of method and primal awareness in the heart tip debate. Here he draws upon another very common tantric set, consisting in those two plus a third quality, nonduality.¹⁹³ Again, the male quality of method is associated with actively pursuing a goal through skillful means, while the female quality of primal awareness has to do with understanding the emptiness that underlies those skillful means. Nonduality would be a mediating factor whereby everything is fluid. By arguing that those in whom the male quality of skillful means is predominant will have a male pulse, and so on, Zurkharwa is tying the kind of pulse to these old tantric gender tropes for personal style.

Also worth noting in his discussion is the idea of predominance, another import adapted from Buddhist scholastic terminology. Predominance (Pali/Skt. adhipati) is one of the classic Buddhist kinds of conditionality, often invoked in epistemology and karma theory to address how the inevitably complex combination of disparate factors in human experience comes to have a defining character.194 Its use now for a medically based notion of gender facilitates a discussion of sexual heterogeneity and the possibility of flexibility and deviation. In Zurkharwa’s account of pulse, predominance implies that all three gendered qualities will be present together, and that people are not entirely governed by method or primal awareness or nonduality alone—or by maleness or femaleness or third sexness, as those notions are understood here, alone. It is only that one such feature rises to the top, to become the leader of the pack, as it were, and thereby affects or organizes the quality of the whole, which is reflected in the nature of the pulse.

Zurkharwa’s reading of the pulse doctrine is of a piece with his solution to the heart tip debate. Both gesture to gendered styles and their analogues in the body. The pulse discussion sheds further light on what he was doing in the earlier debate, as well as how he views tantric categories altogether, particularly his specification that it is all a matter of “figurative” usage.¹⁹⁵ In fact, the foregoing passage brings up the tantric channels not to explain pulse but rather to consider another example of figurative usage. The same kind of association that obtains between the pulses and the gendered monikers with which they are labeled in the Four Treatises also pertains to the relationship of both the three kinds of pulse and the three tantric channels, and the qualities of method, primal awareness, and nonduality. Both the pulse monikers and the trio of qualities are cast as figures of speech, special kinds of suggestive designation. This tells us something important about Zurkharwa’s understanding of the tantric channels: like the pulse types, they are associated with what we might call energy styles, or gendered orientations. In Zurkharwa’s recourse to the tantric channels in explaining the heart opening too, the channels seemed to be a way of talking about personal tendencies that make for certain bodily patterns.

Mind you, such a reading still does not exactly explain why the heart opening faces in different directions in males and females. It just displaces the problem to a putative difference in directionality in the male and the female regarding the mind and the heart. But it does suggest that all these things—pulse types, tantric style types, gender associations, perhaps even the very disposition of the tantric channels themselves—are in some sense figures of speech, or ways of crystallizing or sedimenting what are really tendencies, orientations, and shifting and shiftable patterns. They are tendencies and patterns that readily lend themselves to metaphor. And that helps us to understand how tantric Buddhism, itself so rich in meaningful symbols and figures, becomes a useful handmaiden even for a medical theorist who is trying to make his theory match empirically verifiable data. It helps him describe aspects of human existence and experience that are not readily determined by bodily examination alone. Zurkharwa mobilizes the tantric vision to serve as a central explanation for human difference. Perhaps the more empirical medicine gets, the more it needs to look for conceptual tools to explain the significance of its findings.

One final aspect of Zurkharwa’s foregoing pulse discussion deserves highlighting as well. Actually, his ending comment that “from one perspective, it is said to be uncertain.” echoes Tashi Pelzang when he said, “Most children will be in accordance [with the sex suggested by the parents’ pulse].” Both statements indicate that most people’s sex will indeed line up with their analogues in pulse pattern, be that their parents’ or their own. But like Kyempa did with respect to menstrual flow, both Zurkharwa and Tashi Pelzang open the door to deviation. Tashi Pelzang points to the fact that sex is not entirely predetermined by the pulse mix of a child’s parents. He also allows sexual identity to change over the course of life if the mind stream and karma change sufficiently. In some ways he is less physically deterministic than Zurkharwa makes him out to be, although some of his statements betray a certain confusion and sometimes a collapse of gendered categories with sexual identity.196 Zurkharwa himself is clearer and gestures robustly to the possibility of deviance from norms—of anatomical sex, pulse type, gender proclivity, or what have you.

Thus while both Tashi Pelzang and Zurkharwa show a general expectation that gender follows sex, both also make sure that there is room for individual difference. Most important, both suggest that the connection among the categories of sexual identity, pulse, and mind stream are variable and subject to many intersecting factors, among which human conception and culture play a significant part. Tashi Pelzang even admits that there is no such thing as a pure or singular type, either of person or pulse, other than in name.¹⁹⁷ It would seem to be an important point for medical science to realize.

One of the points that has emerged in the foregoing is that male agendas, male prerogative, patriarchy—the war of the sexes, if you will—determined at least some of the treatment of the female in the Four Treatises. The social fact of patriliny—not often named so overtly elsewhere in Tibetan literature—along with the barely concealed claim to patriarchal privilege are used to legitimize and explain the male triumphalism in the rotsa section.198 It is not so surprising that smuggled in with these social patterns is a tendency to blame women whenever reproduction goes wrong, and to ignore their investment in sex going right. Medical knowledge served as a discursive site for the advancement of male privilege.

What is unexpected in this environment is the flickering self-consciousness and occasional gesture toward egalitarianism.¹⁹⁹ It would be interesting to compare the record in Buddhist literary and social history on similar issues. The androcentrism, patriarchy, and misogyny seen in multiple Buddhist contexts have been well studied, along with a number of extraordinary scriptural moments when gender and enlightenment were intentionally decoupled, and even a few cases where the female gender was assigned superior virtues.²⁰⁰ Such laudable efforts to respond to an otherwise widespread Buddhist androcentrism may have reflected ethical commitments, a sense of justice, a need to build community among religious virtuosi, a strategy for garnering lay patronage, or even the agency of strong and influential women. But I don’t see evidence of any such factors in the medical case. Rather, when the physicians point out variations in menstrual patterns, question whether the male body should be considered the norm for all medicine, or notice gender deviation, these passages suggest more than anything a set of pragmatic needs: more healthy and predictable production of offspring, more accurate scientific knowledge.