by Craig Klugman, Ph.D.
In Jeffrey Eugenides Pulitzer-Prize winning novel Middlesex, readers are introduced to a protagonist, Cal Stephanides, who is male with female traits. This best seller helped to bring into the mainstream consciousness the notion of people who are born intersex—having characteristics of male and female sex organs. Or more generally, a person born with sex organs that fall outside what is considered the male or female norm. For example, a girl with a very large clitoris, or a boy with a very small penis or scrotum that looks more like labia. This category can also include a girl who has XY chromosomes, or a child who appears to have the genitalia of one sex and internal organs of the opposite sex. Depending on the source estimates of the extent of intersexuality range from 1 in 2,000/ 1 in 1,500/ 1 in 2,500/ or 1 in 150 births.
The traditional treatment for intersex children was surgery early in life that changed their genitalia to give them a traditional male or female sex. Thus, a boy born with a very small penis may be made into a female. The physician often makes the decision on how small is too small for a penis and to what sex the child will be assigned. Sometimes the parents would give consent but often the physician would just make the decision without informing the parents. A lawsuit in South Carolina brought by a child’s parents against the state and medical system concerns their 9-year-old child who was surgically assigned a female sex before adoption, and now identifies as male.
Many children who were surgically sorted into one sex or the other have had lifelong battles trying to accept their assigned sex. Countless stories document the experience of an individual struggling to be the assigned sex leading to psychological, social and even physical problems later in life.
Anne Fausto-Sterling has written about the problems with viewing sex as a dichotomy. Instead, she says that we should recognize there is a spectrum of sex ranging from female, ferms (female pseudohermaphrodites with ovaries and some male genitalia but no testes), herms (true hermaphrodites with one testis and one ovary), merms (male pseudohermaphrodites with testes and some female genitalia but no ovaries), and males.
The concept of sex and gender are fluid and not the same in all cultures. For example, an androgen insensitivity syndrome known as guevecodes occurs in certain populations in the Dominican Republic. Children are born with female looking genitalia and are raised with that gender identity. However, around puberty, they suddenly grow a penis and then shift into a male gender role including fathering children. Many North American indigenous groups as well as groups in India, Bangladesh, Pakistan, Polynesia, and the Balkans among others have a fluid third gender which are neither male nor female in social role.
In recognizing the wider variety of human sexes, in late 2013, Germany became the first country in Europe allowing a newborn to be registered as neither male nor female. This is accomplished by permitting the category of “sex” on the birth form to be left blank. The goal is to allow families with an intersex child to take their time in choosing a gender and a sex. Although Germany is the most recent country to recognize more than two sexes, it is not alone in this action. Since 2011, Australia and Bangladesh have allowed an unspecified gender option or “other” on passport applications. New Zealand permits indeterminate sex on the birth certificate and since 2012 permitted the same on passport applications. Since 2009 India has permitted a third gender on voter lists while Nepal has a third gender on census forms (since 2007) and Pakistan on national identity cards in 2011.
The Intersex Society of North America suggests avoiding sex-determining or sex-normalizing surgeries until the child can decide. They do recommend giving the child a gender (saying this child is a boy or a girl) and raising the child with that gender role. The difference is that gender is a social role that can be changed without medical procedure if the child later decides to. Sex is a biological construct and once sex-assignment surgery has been done, it is difficult if not impossible to reverse. Plus, may intersex people choose to not alter their genitalia at all.
In a world where biology has to take a backseat to law and policy, the tendency is to force individuals into preconceived categories. In this case, surgery has been a blunt instrument to reshape healthy human bodies to meet social expectations. The result is usually hardship and suffering. Policy and law needs to change to acknowledge biological reality. And as a society we must make efforts to assist intersex individuals feel supported. For example, my university has a map of neutral bathrooms (usually designated as “Family” restrooms).
Health care providers also need to take a stand and refuse to perform sex-assigning surgeries on intersex children until the child is capable of being part of the decision-making process. Forcing a sex on a child is a real physical and psychological harm. Patients, especially children, need to be protected. Medicine should not be used as a blunt instrument of social norming or as a tool of any political agenda.
The United States should follow the policies of nations such as Germany and Nepal and offer an “other” category for sex on government forms. Such efforts may lead to greater acknowledgement and perhaps eventually acceptance of intersex. Social discomfort is not a reason to discriminate or to force an individual to undergo life-altering surgery. While in general, parents are permitted to decide for their children, something so profound as a person’s sex biology and gender identity should be an area where we permit people to decide for themselves. As long as there is no physical harm to putting off surgery, the decision should not be made until the child can assent, or even better, reaches an age of majority and can consent.