Friday, April 29, 2011

Intersex Genitalia Illustrated and Explained

There is a lot of variation in how the genitalia develop from person to person in all of us. Nature provides us with a wide spectrum of forms, onto which our society imposes two absolute categories of male and female. In my last post, I described how all people start out with the same genitals in the womb, and how the phalloclitoris differentiates during development. In this post I will discuss the range of natural genital forms, explaining how they develop from the shared embryonic phalloclitoral structures.

I will illustrate this post with simple diagrams. I know that there is a lot of interest in what intersex genitals actually look like—most of the people who find this blog do so by searching for these words. I've discussed elsewhere why I will not post medical photographs of intersex people's genitalia—these often picture children photographed without their consent, and I will not participate in their exploitation. But I do support people's impulse to know more about the range of human forms. I want to help lift the veil of medically-enforced secrecy that makes our bodies invisible, so that interesex bodies can be demystified and accepted. So: diagrams it is.

I will start by reviewing the structures of our shared original genital form, and showing how they develop in what are deemed “normal” males and females.

The Embryo

We all begin life with genitals that have four basic external elements. At the top is the part numbered 1 and colored pink on this illustration: the sensitive end of the phalloclitoris, which can differentiate into the head of the penis or clitoris. Below it is structure 2, drawn in orange, which is capable of differentiation into either a phallic shaft, or clitoral body and labia minora. In the center is structure 3, drawn in green: an inset membrane that can widen or can seal as the fetus develops. It will form the urethra, and the vagina, if any. And at the outside is the fourth part, colored blue: the labioscrotal swellings, which can develop into labia majora or a scrotum.

Normal Differentiation”

You can see how the four sectors of the embryonic genitalia differentiate in the diagrams of “typical” male and female genitals pictured here (illustrated without the foreskin or "hood"). Click on any illustration to see it larger. Notice that the pink phalloclitoral head points downward in typical female development and upright in typical male development. The orange body of the phalloclitoris separates and is buried beneath the labia in females, while it closes around the urethra and forms the penile shaft in males.

Sex variance occurs in many forms, but they are not random. Intersex conditions are produced by regular patterns of variation in development of one or more of the four parts of the embryonic genitalia. Let us consider a series of intersex conditions to see how these variations arise, and how they are framed by doctors.

Aphallia”

Aphallia the term given by doctors to a form of sex variance produced when the first two sections of the embryonic genitala do not develop. While this is equally likely to occur in individuals with ovaries as those with testes, it is only generally commented upon medically when the individual has testicles and XY chromosomes. This illustrates how Western medicine is permeated by a strong gender bias. Having a large, erectile penis is considered a necessity for males, and its absence a tragedy of the highest order, to be addressed by somber medical articles. Having a clitoris capable of sensation and erection, however, is given little attention—so little that its congenital absence is treated as worthy of nothing more than a footnote.

The gendered beliefs that permeate Western medicine are further illustrated by the treatment plan for infants with testes who have aphallia. American doctors typically give these children sex reassignment surgery to remove the testes and create a vagina, it being apparently impossible to tolerate the idea of children being raised as boys without a penis. Without this surgical castration, the children could grow up to be fertile, but their fertility is medically sacrificed without their consent. What is particularly noteworthy is that doctors speak of the sex-reassigned patient with aphallia as growing up to have “normal female sexual function.” “Normal,” for a female, is thus medically defined as being capable of receiving a penis in a vagina, not having sexual pleasure.

Microphallus”

Some people have large feet and some people have small ones; some have large noses and while others' are petite. When the phalloclitoris is quite small in a person with external testes and a male genital configuration, doctors say the individual has “microphallus.” If the testes are deemed "inadequate," doctors often advise sex assignment to female in infancy as they do in the case of aphallia, because life as a man with tiny sex organs is deemed tragic. Again, the individual's fertility is sacrificed without consent. If the testes are considered normal the child may be treated instead with injections of testosterone, in effect triggering puberty in toddlerhood and leading to moderate enlargement of the clitorophallus (along with other premature pubertal effects such as the development of adult patterns of body hair).

Rarely considered as options by doctors are simply allowing the child to live life as a male with a small penis, or to decide for zirself what course of action to take. Whether the sacrifice of some or all sexual sensation to have genitals that appear female is better than living life as a person with testes and a very small phallus is not a question that science can give a single “correct answer.” It is a subjective and highly personal decision, and will be driven most strongly by the gender identity the child grows to develop. I and other intersex advocates believe that only the intersex person can make such a lifechanging decision, and that for doctors to force their choice upon an unconsenting child is both arrogant and cruel.

Clitoromegaly”

When a child with typically-male-configured genitals has a large phalloclitoris, the doctors make admiring jokes with the parents. But when the child is female, having a large phalloclitoris is deemed a “birth defect.” Despite the lack of any functional harm from having a large clitoris, doctors perform surgery to “reduce” it to the “acceptable” female range. This often seriously impairs sexual sensation. Although today doctors like to brag that they preserve sexual sensation because they have abandoned the older surgical treatment of “clitoral amputation,” usually some sensation is lost in “clitoral reduction,” and sometimes the phalloclitoris loses all sensation, even though some of the tissue is permitted to remain. It is especially ironic that the removal of part of the clitoris in traditional female circumcision practices is renounced as “female genital mutilation” by Western doctors, yet they perform a similar procedure in cases of “clitoromegaly” without compunction.

Chordee”

The head of the phalloclitoris bends down in typical “female” configuration. When it does so in a person assigned male, it is termed “simple chordee.” In some individuals, the only atypical characteristic is the folded-down head of the phallus, which is of typical penile size. Doctors present this status as a “malformation of unknown cause,” rather than as a typically-female shape of the phalloclitoris in a male, because they are averse to terming any condition in a child assigned male “intersex.” But chordee is not a random alternative shaping of the penis, as if the penile head might have been equally likely to spontaneously bend in an S-shape. Chordee arises when Sector 1 of the embryonic tissue develops in the “female” configuration, while the rest of the genital development is typically male. Doctors usually suggest surgical “correction” of the phalloclitoral bend, citing locker-room teasing and a purported challenge to fertility. Such surgery presents a serious risk to sexual sensation in the penile head. Furthermore, fertility is not impaired by having a bent or curved penis—the production of sperm is unaltered. Penetrating some partners may be more difficult, but there are many ways to engage in both sexual interaction and fertilization other than via penetrative sex, and only the possessor of the bent penis can decide whether it makes sense to risk the sacrifice of sensation in the phalloclitoral head to make it easier to engage in penetrative sex with partners who prefer a narrow penis. (Some partners may find the phallus with chordee to be more sexually stimulating than a typical penis.)

In other individuals with chordee, the phalloclitoris is of intermediate size. It appears as an intermediary form evenly balanced between the male and female manifestations of the phalloclitoris. Often the individual also has a shallow vagina (discussed below under “hypospadias”).

Whether individuals assigned female at birth may have phalloclitoral heads that do not bend down like a typical clitoris but conform instead to the linear shape typical of males is not discussed in Western medical literature, with its obsession with penises and general disinterest in clitori. I consider it extremely likely that this unnamed counterpart to chordee does occur.

Diphallia”

Section 2 of the embryonic genitalia is generally expected to fuse into a single penile shaft in male development, or to spread apart to form the two clitoral crura around the labia majora in female development. If the genitals devleop along male lines but the two sides do not fuse, the individual is born with two separate phalloclitori, side by side, each associated with one testis and having only one corpus cavernosum. Doctors remove one of the phalli (the one deemed smaller, no surprise there), though as in clitoromegaly there seems to be no functional danger involved in having two clitorophalli. This gential configuration can be associated with actual functional problems like an imperforate anus, obviously a true surgical emergency, but constructing an anus has nothing to do with removing half of the phalloclitoris. Doctors do not deem diphallia an intersex condition—the off-the-cuff reading is that the child is “doubly male”--but in fact the clitorophallus has developed in a manner intermediate between male and female norms.

A rarer bodily form than diphallia is phalloclitoral duplication, in which the embryo begins to twin in the genital region but ceases there—similar to what happens in the case of conjoined twins or people born with three legs. The individual is born with two penises or clitori, which may be located side-by-side or one above the other.

Hypospadias

Physical statuses in which a child develops external testes while Sections 2 and 3 of the phalloclitoris develop atypically are grouped together under the medical term “hypospadias.” Segment 3 of the embryonic genitalia forms the urethra and vagina, if any. In the normative male configuration, there is a urethral opening at the tip of phalloclitoris, and no vaginal opening. In individuals with hypospadias, the urethral opening is closer to the typically female location, and there may be some vaginal tissue. Individuals born with hypospadias in the U.S. today are almost always assigned male, and doctors rarely call them intersex. This is an ideological choice rather than one driven by anatomical logic. The medical belief seems to be that if a child has external testes and the clitorophallus can be surgically reconstructed along penile lines, then the child should be assigned male and no question ever raised in the parents' minds about the child having an intersex status. Doctors believe being seen as less than “fully male” is untenable for a man.

The degree of difference between typical male morphology and the genital arrangement of individuals with hypospadias varies widely. In many, it is simply a displacement of the urinary meatus from the very tip of the penis, as shown in the first illustration above, so that the urinary orifice is located lower on the phallic head, which is of ordinary penile size. Doctors “correct” this in childhood, claiming that having a “displaced” urinary meatus is unacceptable, as it will lead to teasing, and ostensibly problems with urinating in a standing position and fertility. Loss of sensation in the head of the penis, fistulas, and problems with recurrent bladder infections are deemed a better outcome by doctors than perhaps needing to sit down to pee—though in adulthood, many who have had this surgery complain that the side effects outweigh any benefits in their lives. The idea that fertility is impaired by having semen emitted from a position slightly lower down on the penis is laughable.

Hypospadias is measured by doctors in degrees. The greater the degree, the more the phalloclitoris assumes a vaginal configuration. The urinary outlet takes the shape of a small vaginal slit if located further from the head of the phalloclitoris, becoming larger if located further down the shaft, as in the second illustration above. If the urethral opening is located at the base of the phalloclitoris, the condition is termed “perineal hypospadias.” In people born with this configuration, the genitalia appear intermediate between the female norm and the male, with a vagina located in front of or between the labioscrota. Testes are located in the labioscrotum, with surface skin that can appear more close to typical labia majora or to scrotal skin. The clitorophallus is often intermediate in size and the head may bend down in the typical clitoral configuration called chordee. While children with “perineal hypospadias with chordee” have genitalia that look closer to the female norm than the male, they still may not be classified as “officially” intersex by American doctors, and surgery that closes their vaginas, dissects the clitorophallus from the perineum, and repositions the urethra to the head of the clitorophallus is termed a “repair” rather than sex assignment surgery. Such extensive surgery is painful, life-altering, and usually leads to loss of sensation. Furthermore, a substantial number of people born with this intermediate configuration grow up to identify as female, despite their infant surgical sex assignment to male, and bitterly resent having been given surgery that removed their vaginal tissue while forming their phalloclitori into the sensation-impaired semblance of a penis.

Rarely mentioned by doctors in articles discussing hypospadias is that it can be accompanied by intermediate internal sex structures, particularly a large “prostatic utricle”. (The embryonic structure that typically develops into a uterus in more female bodies forms a small “utricle” in the center of the prostate in bodies that are typically male.) In intersex bodies, this may exist as a small or average sized uterine structure within or aside a prostate—the greater the degree of the hypospadias, the more likely there is a utricle, and the larger it is likely to be. It fascinates me that the fact that people with hypospadias often have a uterine structure, evident in any literature search on the prostatic utricle, is rarely mentioned in medical descriptions of hypospadias, while much rarer associations between intersex conditions and cancer are often mentioned in articles on other intersex conditions. I believe it is not mentioned because discussing a uterine structure would undermine the medical framing of children with hypospadias as “boys with a penile malformation” rather than as intersex children.

"Vaginal Agenesis"

In some individuals, external genitalia are formed which appear close to the female side of the spectrum, but Section 3 only creates a shallow vagina or smooth patch of lubricating skin. Internally, such children may have no gonads, or may have ovaries but no uterus, or may have ovaries and an atypical uterus. Individuals with vaginal agenesis are always called female rather than intersex by doctors, even when they have no gonads and will develop no secondary sexual characteristics (such as breasts or facial hair absence/presence) without taking hormone medications. Again, Western medical ideology seeks to define away intersexuality as much as possible.

There is a lot of attention given by doctors to the creation of a vagina for children with genitals that otherwise appear female to them. This is framed as necessary for “sexual functioning,” presuming that forms of sexual activity other than penetration of a vagina by a penis are “not really sex.” As is the case with many intersex bodies, surgeries are often performed which sacrifice the capacity for sexual sensation out of an ideology that this is necessary for “normal sex.”

Female Pseudohermaphroditism”/ Congenital Adrenal Hyperplasia

In some intersex conditions, the four zones of the external genitalia develop so that they look typically male (with urethral opening at the tip of the penis, scrotum, and no vaginal opening) but the individual possesses a uterus and ovaries, and the scrotum is empty. The most common diagnosis in people with such a bodily form is congenital adrenal hyperplasia or CAH in XX individuals. While most any person on the street would say that having both a penis and a uterus is an intersex bodily form, doctors hem and haw, and say instead that the child, while intersex, is a “pseudohermaphrodite,” somehow really female. This is based on the move by doctors almost a century ago to define intersexuality out of existence by saying that only individuals with the very rare condition of having one ovary and one testis, or having intermediate ovotestes, are “true hermpahrodites.” An intersex person with testes was deemed “really male” and anyone with ovaries “really female” by the creation of the term “pseudohermaphrodite.”

At the time doctors came up with the idea of the “pseudohermaphrodite,” sex assignment surgery had not yet been developed. Today, however, doctors insist that babies with CAH should be surgically assigned female in infancy. The language of “female pseudohermphroditism” is used to sooth parents who are shocked at the idea of a doctor cutting off their baby's penis. Doctors tell them that it is not “really” a penis, but is “really a clitoris” that is malformed. The fact, of course, is that all babies have phalloclitori—and that their baby's is exactly like any other typical boy's penis. If doctors were consistent, they'd have to call all men's phalli “malformed clitori.”

In any case, doctors in the U.S. routinely perform what they term “clitoral reduction” on children with CAH—that is, removal of almost all of the phallus--and cut apart the scrotum to give it the form of labia majora. In pressing this surgical sex assignment plan, doctors present parents with an odd assessment of the risks and benefits of such a course of intervention. They gloss over the fact that cutting off most of the phallus seriously impacts adult sexual sensation. They tell parents that this must be done to avoid the catastrophe of adult menstruation through the phallus. (Note that they do not inform parents of children with perineal hypospadias that menstruation is a “danger,” or suggest that children with hypospadias be assigned female to avoid penile menstruation.) Doctors do not inform parents that an alternative would be hormone treatment to suppress menstruation, or that their children could grow up to identify as men and function sexually as males, albeit without semen production. (Some ejaculation could be possible, but it would not contain sperm.) Rather than warn parents that many children with CAH grow up not to identify as female and to despair over having been effectively castrated, they warn that the children “have a heightened risk of lesbianism,” which is an eye-goggling assertion that is both homophobic and ignores the issue of gender identity.

Male Pseudohermaphroditism”/ Androgen Insensitivity Syndrome

Children with complete androgen insensitivity syndrome or CAIS are the counterparts to XX CAH children. Their external genitalia take the typical female form, but internally they lack a uterus, and in the place where one would ordinarily find ovaries, they have internal testes. Because their bodies do not respond to testosterone, they grow up to develop very feminine secondary sexual characteristics at puberty, though they will never have menstrual periods. Despite their typically-female appearance, doctors call these individuals “male pseudohermaphrodites” because they have testes. However, in contrast to the treatment of children with CAH, doctors do not go on to say that they CAIS children have “malformed penises” that must be surgically altered to fit their “true sex.” Instead of urging genital reconstruction, they tell parents to raise their CAIS children as girls, warn parents that their internal testes could possibly present a risk of cancer, and tell them to have the testes removed.

Unlike children with CAH, who often regret their sex assignment surgeries, individuals with CAIS seem to usually accept having been assigned female at birth. This is probably because of the contrast in the intersex individuals' experiences. Children with CAH are assigned female at birth via traumatic, scarring surgeries that impair sexual sensation, and then must take testosterone-suppressing drugs for life, while those with CAIS may not find out about their condition until puberty, retain uninjured and unaltered genitalia, and take no hormone-suppressant drugs. Nevertheless, despite typically identifying as female, these individuals are termed “male pseudohermaphrodites” on all of their medical records, and must live with the consequences of being deemed medically male throughout their romantic and sexual lives.

Some children have Partial Androgen Insensitivity Syndrome or PAIS. They are born with a wide range of phalloclitoral forms, from looking quite close to the male iconic form, to forms like that illustrated under “perineal hypospadias with chordee,” to looking typically female. Most have an intermediate form and are given childhood sex assignment surgery to one dyadic norm or the other. As usual, such surgery is traumatic, scarring, does not result in genitalia of fully “normal” appearance, and puts sexual sensation at serious risk. This probably explains why a third to half of individuals with PAIS grow up not to live as the sex they were assigned, while 80% of individuals with CAIS identify as “fully female.”

Those Not Pictured

Many bodies vary from sex-dyadic assumptions in ways that are not visible externally, so that they are rarely diagnosed at birth, such as variations in the sex chromosomes. We are told that “men are XY and women are XX,” but there are XX men and XY women who are not visibly distinct in their bodily forms from those with typical chromosomes. There are many individuals with XXY chromosomes, termed Kleinfelter's syndrome, with a typical male genital configuration but small testes—about 1 in 500 of people raised male turn out to have this intersex karyotype. People often only discover they are XXY when undergoing tests due to infertility, or sometimes in cases where they develop substantial breasts (“gynecomastia”). Another fairly common genetic variation is to just have a single X chromosome with no second sex chromosome at all, which doctors term Turner Syndrome. Having only 45 chromosomes instead of the usual 46 is associated with a host of physical problems, and the fact that the individual's gonads never develop is treated as secondary to the many physical and mental challenges the individual faces.

Other intersex conditions exist on a more macro level than tiny chromosomes, but are internal and so may go undiagnosed for years or for an individual's entire life. Included among these, ironically, are the only conditions deemed to constitute “true hermaphroditism” under medical taxonomies: the presence of an intermediate ovotestis, or even more rarely, of an ovary and a testis in the same person. I'll write more about “true hermaphroditism” in a later post.

Also not pictured are the bodies of people with an atypical sex steroid balance between the feminizing hormones (estrogens, progesterone, etc.) and masculinizing hormones (testosterone and its byproducts). Everyone produces all of these hormones, and requires both types for fertility and physical health, but those with bodies on the female size of the spectrum typically produce more feminizing hormones, and those with bodies on the male side typically produce more masculinizing hormones. Variations in this balance lead people with typically-female genitals to have higher levels of body and facial hair, muscle mass, likelihood of balding, and libido, and people with typically-male genitals to develop breast tissue, more curvaceous hips, etc. These variations are not termed intersex by doctors, but there is no logical reason why they should not be. Their intersex character is denied because most adults with such conditions have normative gender identities that match their genitals but are challenged by their contrasting secondary sexual characteristics. They and doctors together strongly assert that their variations do not make them any less male or female. While I agree that no one's gender identity should be deemed undermined by their physical appearance, I believe it would help all sex and gender variant individuals if society and medicine would acknowledge the prevalence of physical sex variance while supporting individuals in their gender identity assertions. Some intersex activists disagree, wishing to limit the conditions that will make a person “count” as intersex, and patrolling the boundaries of the community to exclude others as “wannabes.” Personally, I find this cruel and counterproductive. A woman with a beard lives a life in which her sexvariance is very visible, and saying she can't be included in a community of those with sexvariant bodies because she has typically-female genitalia does not make sense to me.

Another category of hormone-related variance includes individuals who produce low levels of sex steroids and whose bodies do not change much at the usual age of puberty. Such individuals are almost always treated with sex steroid therapy, without presenting them with the option of living in their androgynous bodies medically unaltered.

Finally, let me note that this catalog of intermediate bodily forms is not exhaustive. In my understanding, anyone whose body varies from the iconic male or female dyadic norms is sex variant, cannot be wished out of the intersex rubric by tricks of medical terminology, and should not be excluded from intersex community by gatekeepers.

We need society, the medical field, and intersex communities themselves to acknowledge that nature provides humanity with a wide range of forms, so that all of our bodies can be recognized as valid. Unless there is an actual rare functional problem, our bodies should not be altered in infancy, and only those functional problems should be addressed. Our genitals should be altered only if we ourselves request it, to make ourselves comfortable in our own skin, not to make society comfortable by our medical erasure. Society must come again to embrace the diversity that is nature's gift to us.

58 comments:

  1. Thank you thank you!

    I've been curious about genital variation but I didn't want to google pics or ask intersex people since its so invasive.

    The illustrations are wonderful, and give a better idea of what develops how than a real photo could. Plus no worrying about whether the subject of the photo consented!

    Its interesting to see how biased the medical profession is when it comes to sex organs. The double standards are seriously creepy.

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  2. I fully agree with the first comment.

    Also, thanks for shedding light on how closely "classical" sexism, gender stereotypes and prejudices against intersex people are connected.

    Yay for keeping up the roadshow!

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  3. Thank you, Anonymous, for your kind comment. I'm no great artist, so I'm glad to hear you find my illustrations illuminating.

    Keris and Anonymous both comment on how gendered double standards and sexism permeate the approach of the medical profession toward intersex individuals. I can but affirm this is so.

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  4. Thank you for this wonderful article. As 'Anonymous' stated, your illustrations serve a far more useful and descriptive nature than any photos ever would.

    While the prejudice and sexism in Western medicine is indeed horrifying and saddening, it is also sadly reflective of our societies as a whole. The sooner our world embraces natural human diversity in all its forms, the better we will all be for it and the more we will enable ourselves to grow as a race.

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  5. Thank you for this article. It was great to see an Intersex doctor out there! At long last, some one of equal qualifications to tell the medical profession from the inside how it is. I really like your approach to this as well. if there is not an emergency medical issue, leave things how they are. Don't doctors sign the Hippocratic Oath" to do no harm? Or is that the Hippocritic Oath?

    I also really like your personal motto thingy at the top right of the page. As an intersex person I'm fed up of being told to hide myself or to be ashamed of who I am.

    Good on you for this post, and your entire blog. I shall read more after I've finished writing this damn uni assignment.

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  6. Mianne, I'm glad you find the illustrations useful, and I agree that it is time for Western society and medicine to embrace embodied diversity.

    Romana, I'm pleased you like my motto and the blog! I must let you know, however, that I am not an M.D., but a Ph.D.-style doctor who studies, among other things, the sociology of medicine.

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  7. Thanks for writing this up, it took me a while to get through it but it's very informative (as others said, much better than googling and having weird stuff show up). I know you glossed over hormones and internal organ configurations, but I was wondering if there's a similar way to explore these variations? It's fascinating how many natural expressions there are, and we are only ever taught about 2.

    The "classical Western" lens is eerily present everywhere, and it's good you call it out.

    (And it's still unbelievable to me that society will mess up a person's life even before it begins because of their non-standard genitalia.)

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  8. I love, love, LOVE this blog! Such a fascinating, informative, and eye-opening read. My only complaint is that it is not updated more often. :) I'm a cisgendered woman who got into exploring intersex issues through the issue of infant male circumcision, strangely enough -- not to hijack this blog or anything, but that's where it started for me... questioning the ethics of infant circ and from there questioning what is done to intersex people and others.

    It's been a very depressing journey for me at times, since I realize that if I had been born visibly intersex or visibly male, then I might have been operated on without my consent. It's a pretty thin (and in some cases, nonexistent) web of protection that shelters our society's children from such things, and it's horrifying to realize that as an adult.

    Well, having written this, I realize I've said nothing about this post in general. I liked the illustrations and found them informative as to the variations out there. As another commentator suggested, perhaps a second post is in order, for internal anatomical differences? :)

    Or, perhaps a post for those who are allies of intersex people/intersex rights, but are not intersex themselves?

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  9. Wow. i'm really glad I found this blog. This post in particular was very informative, and has helped me get some more answers about things (I'm intersexed, myself), though I'm still figuring things out. Excellent blog, Doctor.

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    1. I am male but interested and attracted to intersex persons with feminine behaviour...

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  10. Spectacular article. One minor nitpick! The plural of 'clitoris' (and hence of 'phalloclitoris') isn't in -i, it's in -ides. So, 'clitorides', 'phalloclitorides'.

    /end linguistic nitpick

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  11. Excellent article, thank you for posting. It is so rare to find a Doctor, any doctor who is even remotely aware of these issues. I just wish more doctors would consider for a moment the harm they are doing to the child, instead of the good for the parents.

    Onnineko

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  12. Now you can talk with doctor very easily .

    For info visit :www.dialurdoctor.com

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  13. These diagrams confuse me. Why don't you show some photos instead?

    (and then everyone in the Internet will think I'm a perverted that only wants to jerk off at strange genitalia)

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  14. Wow, thanks for this. Very enlightening.

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  15. Thank you for this very informative article! I knew some of this, but not in such detail, and your illustrations were very helpful for understanding too. Will definitely share this on so more people can learn about the beautiful diversities of the human body. :)

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  16. Thank you so much for this. Was informative without being invasive, and gave us the correct terminology without being confusing.

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    1. Thank you for the comments of support! I'm very glad people find this post helpful.

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  17. Thank you very much for making this post and sharing this information. It is VERY helpful and I look forward to helping others to understand the various forms of sexuality in a more accepting framework.

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  18. Sent here after a discussion on uterus didelphys at Pharyngula.
    An excellent and informative article! Special thanks for noting the tendency towards othering children who are not "typically" male. I will be sharing this many times........

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  19. Thank you very much for this. I did not realize the appalling extent to which doctors will go to fit bodies into boxes.

    As a non-intersex, non-binary trans person, this also helps with how I conceptualize my body. That just because some doctor looked at my genitals and pronounced in all their power "female" that that is not who I am.

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  20. Thank you so much for this article. It was very interesting and helpful in better understanding this topic.

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  21. A fantastic article! Thank you so much for your clear drawings & explanations. Keep up the good work :)

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  22. Thank you so much for this article. I'm especially appreciative of the paragraph at the end regarding persons with 'atypical' hormonal balances. I've had excessive androgens and testosterone since puberty, suffered medical tests and treatment to which I did not consent as a child (which gave me PTSD), and I was heartbroken to not find acceptance when I first reached out to the intersex community. Whenever I find a blog that is so inclusive and also informative, it brings tears to my eyes. Thank you so very much!

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  23. Thank you for this post, it was very informative.

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  24. Interesting article. say us how nature can be varied.

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  25. Thank you so much for this! Very helpful and informative. ♡

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  26. Brilliant article. Should be required lecture for all pregnant people and their partners.

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  27. Your blog is fantastic. I've worked as a sex educator for several years, and my employer has me doing research for a comprehensive set of educational diagrams depicting variations in genital anatomy. This article in particular is so inclusive and thorough in its factual organization! I can't tell you how valuable it is to find this much information about intersex genitalia in one place. I also love how your blog is anchored in such a progressive, compassionate point of view. Great ethics and clear, intelligent writing. You rock.

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  28. Great blog... it is great to find all of this information all in one place. You probably already know this, but related to hypospadias are the more complicated conditions called bladder and cloacal exstrophy. If anyone is interested in learning more about these conditions (that often impact sexual reproduction and prompt infant surgeries) you can visit:

    http://www.bladderexstrophy.com

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  29. You failed to mention those of us who are male-female chimeras who have ovaries, testes & ambiguous genitalia.

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    1. Is it normal for male to be attracted/interested to shemales (male-females)?...Tha

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  30. Curiosity bought me here and I leave enlightened.

    A great read for those in the medical profession or those looking to find out more about the world around them.

    Thanks! :)

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  31. I am male but my body produces more feminine hormones so i have a very girly body shape
    the only male characteristics i have (besides my genitals) are facial hair abd wide shoulders. I have all the other female characteristics, including emotionaly

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  32. I am intersex, but was raised male. I was born with hypospadia, a penis on the smaller side, and undescended testicles that were later surgically lowered (at adulthood) but do not produce sperm. When I was approaching adolescence, I was not like other boys in the things I liked to do. I was considered boyishly handsome and was popular with the girls who I enjoyed being with socially and sexually, but I was uncomforatble around boys. Sex was fine, or so it seemed. Later I discovered sex with men and my world changed. I had gynomastia that I had surgery cut but it grew back. I am not fat or out of shape...just girly in ways. I sometimes feel like I am a male and a female twin in the same body, from a social, emotional and sexual standpoint, and it drives me crazy. One time I dressed in drag and all were shocked that I looked so convincing. Puting on makeup, hair, and dresses seemed natural. I live now in Palm Springs where I have found the most acceptance. It is tough finding acceptance, though, as we are not always welcome by str8 or gay folks but viewed as freaks.

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  33. Hi,
    Thank you for the time you spent conducting research and for sharing this article. It was very informative.

    I was born a female with aphallia (No clit). And a very small vagania etc. This has affected me in many ways. Mentally, and sexually on so many level. I have never had an orgasm. It is very difficult for me to have a relationship or to trust that my partner will understand or respect my privacy and not gossip about me. Or not mock my pain.

    I would like to know if there is an organization that can provide support, or if surgeries are advanced to help? I often feel very alone. This condition is extreemly rare.

    The GYN I went to are not knowledgable or supportive thus far. I feel like I am treated like its no big deal and nothing can be done etc. I think there is hope for me. I just haven't found the right doctor yet. please send me information that is helpful to my situation.

    Thanks

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  34. Extraordinarily well written and the definitive source for questions related to inter-sex realities. This was done in an informative and respectful tone that is so lacking in the medical establishment regarding anything that falls out of their view of the "norm". Having lived in southeast Asia for many years, I can say that those we call the "third world" are far ahead of western notions of sexuality and the endless varieties one finds among our fellow humans. Thank you for your erudite efforts in making information accessible that most medical western practitioners no next to nothing about.

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  35. Thank you for this.. It disgusts me how we aren't taught this and how society tries to mold an entire sex out of existence because it is "different".

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  36. This article is so important! I look forward to filling in the gaps left in our binary-sexed system with the information you provided.
    One thing you didn't mention is the way that visibly male and visibly female individuals are also encouraged to heighten sex dimorphism via breast augmentation/gynecomastia reduction, shaving or not, types of exercise that emphasize muscle bulking versus body toning (getting "big" versus getting "skinny")... the list goes on. Also the way that clothing is cut, bras are designed, etc. all generate an illusion of a far greater sexed body difference than actually exists. Of course behaviors like these are choices, and cannot compare to the violence of nonconsensual surgery on infants and children (although they may be the result of social pressures and cause of further social pressure), but I mention this because these choices which heighten perceived normative sexual difference also contribute to the construction of a false purity of sexed bodily form.

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  37. I am a female whose body produces too much testosterone, therefore I am considered abnormally hairy. Hirsutism in female is not seen as something that make them intersex, though it can lead to sterility, but it is still treated through hormonal therapy. I refused it because it tends to have very negative side effects, but I have a friend who is being treated for that.

    So, while it's not "intersex", it's still seen as a defect for women.

    The thing is, it shows how arbitrary the definition of intersexuality is and how much doctors and people are reluctant to accept anything that does not fall neatly into their category.

    Hirsutism doesn't make me unhealthy. My friend has become obese, suffers from hair loss and depression because of her treatment, but it's not seen as an issue compared to her hirsutism because, at least, she looks like a "normal" woman.

    I've also never understood why so many people considered it normal to force intersex people to undergo surgery and treatments so that their genitals might end up "looking normal".

    Every one has different looking genitals anyway. It really makes you think that biological sex is just as much a social construct as gender since not all sexes are taken into account.

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  38. Wow...very interesting stuff! I don't have children yet, but if I do...and they have any problems like these...I think I will consult here first, and with many doctors before any decisions are made. I can't believe doctors just hack away at babies thinking they know what's best. You can't just undo those things...and that affects the rest of their lives. Wow.

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  39. This article is exactly what I hoped to find to help me explain how neither gender nor sex is binary. Absolutely love the easy to understand diagrams!!!

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  40. Thank you. This is really helpful - I am working on an LGBTI project and as a gay man I have struggled to grasp some of the potential sexual and (resultant) relational issues facing intersex people. Your writing and pics provide me with a really helpful starting place. Best wishes, Warren.

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  41. thank you for this site this has helped me to not feel like such a freak... thank you thank you thank you

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  42. UTRICLE!

    I have conferred with a confederate, and we agree that this is the cutest name for anything ever.

    It sounds a great deal like a type of Pokemon.

    But it is probably somewhat harder to release from its protective ball so it can leap out and battle your enemies.

    But perhaps not impossible.

    Metaphorically speaking.

    Or maybe by way of practicing an obscure and highly-disciplined martial art.

    I am now strongly considering drawing a chibi version. Thoughts?

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  43. I've just discovered this blog and it's really consciousness-raising... However, I have a little correction: "clitori" is an improper form. "Clitoris" belongs to what is called third declension in Latin, with genitive "clitoridis" and plural "clitorides". In English, both the Latin plural "clitorides" or the anglicized plural "clitorises" are acceptable.
    A very interesting article on plural forms of some foreign words (Latin, Greek and others): http://www.straightdope.com/columns/read/2139/what-is-the-plural-of-penis
    I happen to speak some Latin, so I notice such errors, but the article provides a lot of knowledge anyway. And it began just with a question about the plural of "penis"...
    PS. Sorry for any mistakes _I_ may have made - English is not my first language as well.

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  44. This was excellent as an educational guide! Very well written. I am in total agreeance with your comments on Western Society. Medicine is still in a very barbaric stage, IMO. For what it's worth, my intersex child would have no surgury and every choice to be who they want to be. We can't protect our children from everything, but we can be a safe place to fall, and a true source of education on unbias of every nature.

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  45. I really appreciated this guide, but I have to say, I am still stuck in the nearly 10 year mental struggle to figure out if I am fundamentally intersex. I was assigned female at birth and now identify as a host of trans-type things, but I was born with genitalia that in photos look very nearly like a penis & testicles. I once asked my mother about this and she was insistent that sometimes a vulva just is very swollen/puffy at birth; likewise, I got my period at a "normal" age and I think my genitalia for a while looked how people expect for someone assigned female; now the phalloclitoris is substantially larger but that's due to testosterone injections. And yet I also had labial adhesions for many years before puberty, I displayed signs of high androgen levels with my acne & body hair once I did hit puberty, and I don't know, I just can't figure out if my years of misery were unhappiness with female gender assignment or instead profound dysphoria surrounding my equipment (with some kind of non-transsexual source). If I'm not really intersex in any way, I guess it shouldn't make a difference to me, but I've been hung up forever about it and I just can't figure it out!

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  46. Very well written and informative article! While I do agree that that intersex children should not be operated on until they are old enough to give consent, I would just like to point out that the medical community generalizes and puts people in "boxes" because they treat you from a biological standpoint. How you identify your gender means nothing to a doctor who is treating your physical body.

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  47. How enlightening and sad for anyone who is assigned a sexual identity without their express consent. God has made a variety but not a mistake and sometimes surgery is the answer-ie cleft palate, etc not genitals. Let the person with ambiguous genitals decide...

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  48. Thank you very much. This is a clear and accessible article that answered a lot of my questions. Over the last couple of years I've been learning more about both transgender and intersex issues (I'm cisgender myself, and I think it's important to be well-informed in order to treat people of different gender or sexual identities fairly and kindly), and I've been thinking particularly about how they relate to a cisgender parent's decisions about child-raising. I don't yet have any children but I think of it as a possibility. I don't think that, in the society I live in, it's feasible to opt out of gendering your child until they're old enough to express their own preferences (not without isolating them from their community and extended family), but I would want to talk to my children, in stages as their language skills and comprehension developed, about the different possibilities, and to let them know that I had taken my best guess about their gender, but if they ever felt I'd been wrong they should talk to me about it so we could try to make things right.
    Reading about the unnecessary and often damaging surgeries you discuss here, I've also decided that I would talk specifically about the possibility of an intersex birth with my doctor well ahead of time, and let them know that I'm strongly opposed to such interventions. I want to leave any choices about surgically altering the genitals to my child once they grow up, and I think it's better to raise them with the explanation that yes, their genitals are unusual, but that's part of what makes them a unique person, not a problem or a defect. I've read stories from people whose parents took this approach and they seemed a lot more confident and comfortable with themselves than those whose parents did the opposite. Confident and comfortable with themselves is what I'd want my children to be whatever their sex or gender identity.
    And after all that research and thinking, all I can do is hope that things work out for the best, and keep my eyes and ears open for any new information.

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  49. Personally I think overjoyed I discovered the blogs.cosmetic vaginal surgery

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  50. I wanted to write an intersex character, but I have no experience with it, so this is a really helpful resource! I also feel like I learned a few things, so thank you very much for making this for everyone. As a dyadic who doesn't want to offended anyone, but instead bring awareness to people and parents, thank you.

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  51. Great article, I'd like to learn more about xx male and xy women, have you wrote something? I was wondering if someone is born intersex and doctors and parents select the "obvious" sex for the baby, creating the changes in the body, she/he can know that if they didn't tell anything?

    Thanks

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  52. As a reply to Anonymous/ 6 sept. I would suggest reading Lianne Simon's book available at "About Lianne - Lianne Simon". As a reply to Anonymous/ 17 sept. this is close to my situation. In my family, CAH (17a or 3beta, we will soon know which) recurs generationally, resulting in a casual familiarity with what we call 'thin (gender) dimorphism'. I was told by my mother (at age 32) that doctors 'took a while to figure out whether I was male or female'. It was another 10 years before I first heard the term "intersex" and another 11 years that I learned that CAH could cause this condition. So please don't mistake me for an intelligent person. In the meantime, I had grown up (quite obliviously) knowing that my grand uncle was said to be a woman, my uncle (father of three) had a 'pussy' (probably only a pseudo-vagina), and I was never to show anyone my male parts. In the meantime, I discovered at summer camp that other 13 year old boys did not have aa cups, could put on muscle in places other than hips and thighs, did not wait until 22 to start shaving or 33 for their voice to finish 'changing'. My ROTC friends taught me how to walk normal (John Wayne and Babe Ruth never seemed to get this). Although I could rock a size seven (with enough makeup), if I was on a topless beach, I would be equally disappointing if wearing trunks or a bikini bottom. I never questioned why my penis could not depress enough to be useful. I did enjoy being in an all girl witches coven at age 14, never suffering from testosterone poisoning (it affects 51% of the population), and hitting some of the same notes as Belinda Carlisle. Working in an ad agency I would sometimes pickup artwork (from clients that did not know me) wearing an AK2 (Donna Karan design) woman's suit. But the voice did change, the thick hair disappeared, and by age 50 I was shaving every day. Through all of this I never really figured it out. How many others? The worst part was how my few girlfriends would turn me into their older sister by the third date. Did they figure out what I had not? My greatest regret is the years I spent training for male activities my body would never grow into. So please don't mistake me for an intelligent person. - Tupungato.

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  53. Habitual PS: One obvious subtext of my last comment is the need for a mechanism to ensure that intersex persons be informed of their condition at an early age (maybe 10 or 12). A process could exist for this to be deferred, but it should have to require a positive action on the part of the parents. The informative process should involve at least one session with someone who actually knows the material. We know too many stories of teens growing up in ignorance as to why they are different. Also, I may be too critical of my own slowness of self-recognition. I did eventually figure this out without much help. It did not help that when the obvious was presented to a doctor, the reply came back that I must be mistaken as 'ALL ambiguous males are turned into females. So there must be some other reason for the stitches'. Do they teach this in med-school? Johns Hopkins says the ratio of gender assignment is more like 60-40 in favor of female. Also I appreciate the anguish of persons whose sexual expression or enjoyment of sex has been compromised by unnecessary surgery. For some of us though, this is a shared hardship, but one of little importance compared to the daily challenge of living with the side effects of whatever condition put those atypical parts in/on us. My misunderstanding of heredity was one of assuming that genetic heritage had put A-B normal parts in/on me. "So what, most are gone now!" What I learned in time was that genes don't create parts. Genes enable or disable internal engines that create chemicals that create parts. An A-B normal chemical mix can allow a male to have some extraordinary variation leading sometimes to exciting possibilities (I often wonder about Andreja Pegic). But the chemistry that can put female parts in/on a male will often also usually guarantee that function will be compromised. The challenge to such persons (like myself) are the side effects of atypical chemistry which go far beyond gender expression. So while I did consider changing sex to female, I had to concede the reality that I was only marginally employable due to adrenal disability. The male-only jobs available to me would never have tolerated the obligatory 'transitioning'. I sometimes wish I could have become female while just continuing to present as male. Even this would have created such a trauma within the family that I could not indulge this impulse at their expense. I am grateful that In time I would become indispensable to the companies I worked for. But due to my lack of male competitiveness, the companies that would hire me were always marginal with marginal pay. For my brother, living from day-to-day is a challenge. I may soon be like him. Last week we met with a genetic specialist. For the first time we met a doctor who knew more about our condition than I did. For the first time we met a doctor who did not say "You can't possibly have CAH because you don't look like a middle linebacker". All of the previous doctors were only aware of the masculinizing forms of CAH. So the only treatment we have had is that which we design ourselves. I am still employed and we are still alive. So maybe I am intelligent, even if a bit slow. On the brighter side, the style in which I do my job of selling parts is based entirely on superlative memory. I have recently discovered that the cholesterol that does not turn into glucocorticoids makes me infection resistant (nothing normal can touch me); the cholesterol which does not turn into testosterone (I will never suffer from testosterone poisoning) does not disappear, but lingers as pregnenelone which is a memory and cognitive enhancing drug, So maybe all of the things I like about myself are a result of my A-B normal genetics, my disability, and my acceptance of this as a challenge. - Tupungato.

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  54. Thank-you for writing this! It never ceases to horrify me how happy our culture is with infant genital mutilation, whilst knowing that it is wrong when committed by any other culture.

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  55. Very good article.
    i have hypospadias and slight chordee. The split and hooded foreskin can often look like a large clit. They seem to be very similar.
    i have penoscrotal webbing to just below the glans.. like a large labia possibly. And chuck into the mix im small .perhaps 5' tops erect. When flaccid it varies...sometimes just an inch or slightly more. I am considering corrective surgery. Not sure of peoples thoughts

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